The Exchange Club of The Pompano Beach FL
GRANT REQUEST

                                                                                                         [This form must be completed by requestor only]

- The National Exchange Club Mission Statement -

Exchange is a group of men and women working to make America a better place to live through one national project, Prevention of Child Abuse, and other community service projects. 

Organization Name                                                                                                                

Executive Officer                                              Program Director                                                

Address                                                                                                                            

Phone                                                                   Fax                                                                    

Exchange Club Member Sponsor (optional)                                                                          

The Exchange Club of  Pompano Beach FL will consider grant requests for programs that further its interests and those of the community at large. Please provide a description of the proposed program and how it will aid Exchange to meet its goals.

                                                                                         ___________________________________________  

_________________________________________________________________________________________

(attach additional sheets if required – attach copies of brochures and flyers distributed by your organization to the public )

Program Fiscal Year and Duration since inception                                                                          ___________ 

Estimated Total Program Budget Requirements                                     ______________________      

Amount Requested from The Exchange Club of Pompano Beach FL                                   ______       

Please detail how funds will be expended if the grant is approved:                                                                                                    __________________________________

____________________________________________________________________________________ 

Please list the names of other organizations, if any, from whom you have requested grants for the above

program, the amount(s) requested and the amount(s) granted: (attach additional sheets if necessary)

NAME                                                           Date    -    Amount Requested  -  Amount Granted

                             ____________________________________________________________                 

___________________________________________________________________________________

How will your organization evaluate the success of the program and report to the Exchange Club?                                                              ___________________________________________________

__________________________________________________________________________________

Questions?                                        Grant Requests Must Be Received No Later Than May 1, 2003

Contact                                            Completed Requests and supporting documentation should be

(954)                                                       mailed to