GXF Application Form

(Please copy the text into a word processing document so that you can complete it on your computer.)

Common Counsel Foundation

Grassroots Exchange Fund Application Form

Organization Name:

Contact Person and Title:

Street Address:
City: State: Zip:

Phone: Fax:
E-mail: Website:

Name of Exchange or Event:
Exchange/event Date(s):
Grant Funds Requested: $
Organizational Budget: $ Budget for the exchange: $

Tax Exempt Status:
(Please attach or fax 501c3 letter or that of fiscal sponsor)
Fiscal Sponsor (if applicable):

Have you received prior funding from the Common Counsel Foundation? __Yes __No
(Member funds include the Abelard Foundation, Acorn Foundation, Penney Family Fund, Victor & Lorraine Honig Fund, the Social & Economic Justice Fund & the Grassroots Exchange Fund.)



1. Please complete this one sentence, for a brief summary of your request:
If awarded, this grant would…




2. Organization’s Mission Statement:




3. Number of Active and/or Dues-Paying Members:





4. Membership Demographic. In one or two sentences, please provide a broad overview (not necessarily a statistical breakdown) of your member base. We are interested in how your active membership reflects the demographic of the community you serve (in terms of income levels, ethnicity, and/or any other factors which you deem relevant to your work).





5. Community Organizing for Policy Change: In 400 words or less, please describe how your organization is working to increase your base of low- and middle-income members who take leadership on local and regional issues toward social, economic or environmental change. Please note any policy change work that your members are involved in.





6. Purpose of the Exchange or Event: Describe the skills or information sought from the proposed exchange/ event, the urgency of your request, and how information from the exchange will be shared with others (300 words max).





7. Names of those people who will participate in the exchange and their roles within the organization.





8. A budget for the exchange, including a list of potential funding sources:






Attachments

-- Please attach a current annual budget for the applying organization.

-- Please attach or fax a 501c3 letter or that of your fiscal sponsor.

Grassroots Exchange Fund, Common Counsel Foundation, 678 13th Street, Suite 100, Oakland, CA 94612. 
Phone:  510-834-2995, Fax: 510-834-2998, Email: This e-mail address is being protected from spambots. You need JavaScript enabled to view it