2011 Safety Responders Fund Grant Application

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Date of submission: May 17, 2012

Organization Information

Organization Name:
Federal Tax ID Number:
Street Address:
City:
State:
Zip:
Mailing Address:
City:
State:
Zip:
If your organization has a web site, please provide the URL:

Year Organization was Founded:
Check here if your organization is a United Way agency

Organization's Total Annual Budget:
Description of Organization
Description of your organization's mission. Please enter this information ONLY if this is your first time applying to Entergy or if your mission has changed. (50 words or less)
Board Members and Officers
List all board members and officers of your organization. (Please DO NOT include addresses.) Also disclose any known relationships with Entergy, its employees or board members. (100 words or less)
Principal Officer:
Telephone:
Ext.:
Fax:
E-mail:

Project Information

Project Title:
Name of Project Administrator:
Project Description
(Brief description of the project and why it's needed, including evidence to support your view. 250 words or less)
Anticipated Results
(Describe expected outcomes and their benefits. 250 words or less)
Is majority of target population at or below the poverty level?
Yes
No

Project Start Date:
Project End Date:
Total amount of project (not organization) budget:
Amount Requested from Entergy
Awards up to $25,000 will be considered for funding. Requests above $25,000 will be considered extraordinary and outside the scope of the normal grant process.
Other Funding Sources for Project
(List other sources to which you have applied for funds, including amounts requested and amounts approved. If there are no other sources, please put "None.")
Federal/Stimulus Funding
(If your organization has received any federal / stimulus funding please provide that information. If there are no other sources, please put "None.")
Line-Item Project Budget
(List line items, with dollar figures, for the amount requested. 15 lines or less)
Will funds be used for consultant services?
Yes
No

If so, please explain.

Measure of Progress/Performance
(Describe method used to measure the project's progress/performance. For example, collection of specific data such as test scores, survey results, number of clients served, etc. 200 words or less)

Project Administrator Contact Information

Office Phone:
Extension:
Office Fax:
E-mail: