CANTON ASSOCIATION OF INDUSTRIES

PO BOX 190

CANTON MA. 02021

781-828-2555

FUND SCREENING REQUEST FORM

YOUR NAME _________________________________________________________________

ORGANIZATION______________________________________________________________

AMOUNT REQUESTED $_____________ DATE MONEY IS NEEDED__________________

ORGANIZATION MEMBERSHIP #______  ARE YOU A NON-PROFIT ORG?____________

ESTIMATED NUMBER OF PEOPLE THAT WILL BENEFIT FROM THIS REQUEST______

1.       PURPOSE OF REQUEST:

2.       DOES YOUR GROUP HAVE FUNDRAISING ACTIVITIES? ____ IF YES, PLEASE DESCRIBE

FUNDRAISER               DATE       PROFIT                      FUNDRAISER       DATE     PROFIT

3.        HAVE YOU OR DO YOU PLAN TO APPROACH OTHER ORGANIZATIONS FOR  FUNDING?  __________________________

ORGANIZATION        REQUEST AMOUNT        ORGANIZATION       REQUEST AMOUNT

SIGNATURE_____________________________ADDRESS____________________________

_________________________    ________________             ____________________________         

                 PHONE                                    DATE