Casella Grant Application

Organization Name *

First Name *

Last Name *

Email *

Phone

Mailing Address *

City *

State *

Zip *

Physical Address if Different from Mailing Address

City *

State *

Zip *

Other Description *

If yes, what is the date of the event or project? *

Describe the event or project and how the proceeds will be used: *

Please attach the following: • Any additional information to support your request • Copy of tax-exempt notification letter from IRS or equivalent documentation *

Any additional notes/comments?

Consent for storing submitted data *

Yes, I give permission to store and process my data

Requested Monetary Amount *