Good Works Form

EIN:

Amount Requested:

Organization Name:

Mailing Street Address:

Mailing City:

Mailing State:

Mailing Zip Code:

Is the Mailing Address different than the address on IRS tax Documents: Yes No

Tax Classification Type: Individual/Sole proprietor or single-member LLC C Corporation S Corporation Partnership Trust/estate LLC Other

* Note to Corporations: Pursuant to Cal. Corp. Code 313, contracts with a corporation be signed by two individuals, one from each of the following lists of officers: (1) chairman of the Board of Directors, the president, or any vice-president; and (2) the secretary, any assistant secretary, the chief financial officer, or any assistant treasurer, UNLESS the Contract is accompanied by a certified copy of a resolution by a corporation's Board of Directors authorizing the execution of the contract.

Name:

Email Address:

Phone Number:

Name in lieu of signature:

*The party agrees that the electronic signatures, whether digital or encrypted, included in this Agreement are intended to authenticate the information submitted and have the same force and effect as manual signatures. Yes

What will this funding be used for? Please explain: