Please complete the following information on the organization::

Executive Director or Contact Name

Organization Name

Address

Mailing Address (if di erent)

City/Town

State/Providence

Zip/Postal Code

Country

Contact Email

Contact Phone

Year Organization Founded:

Federal 501(c)(3) Tax I.D. No.:

Annual Budget (Minimum $25,000 and maximum of $1,000,000):

Describe the history of the organization and its mission statement. (You may include website(s) or send brochures via mail.):

Describe brieflyy the services your organization provides, including the number of people served:

Full-time Staff Members:

Part-time Staff Members:

Number of Volunteers:

Total number of Board Members:

Approximately what percentage of your funds comes from government sources?:

If your organization received funds from the eWomenNetwork Foundation, how would you envision using the additional funds?:

Does the nominee have a family member working for eWomenNetwork either in the Corporate o ce, Foundation, or as a contractor? eWomenNetwork contractors, employees, and their family members (spouses, parents, children, siblings and their respective spouses, regardless of where they live) or persons living in the same households of such employees, whether or not related, are ineligible for a Grant consideration. eWomenFoundation will determine eligibility at its sole discretion.

Yes

No

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