Prefix Mr. Mrs. Ms. Dr.
First Name
Middle Name (Optional)
Last Name
Organization
Your Title (Use “N/A” if no title)
Organization's Street Address
City
State Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesa Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Outside U.S.
Zip Code
E-mail
Contact Telephone
What is the primary focus of your organization? Arts and Culture Civil and Human Rights Community Development Education Environment Health/Human Services International/Foreign Affairs Religion Technology Other If "Other," please specify:
What is your organization's annual operating budget? Under $100,000 $100,000 to $249,999 $250,000 to $499,999 $500,000 to $749,999 $750,000 to $999,999 $1 million and up
Communities primarily served (Check all that apply): Inner-city/Urban Suburban Rural
Are you representing a U.S. 501(c)(3) organization? Yes No
I understand that the scholarship is $100 and, if awarded, I will be responsible for paying the balance of the course fee. I further understand that the scholarship is not transferable.
Do you agree with the terms of this application? I agree I do not agree
