APPLICATION

Name of Organization: ________________________________________
Address: ________________________________________
Phone #: _______________________________

1. Provide a description of your organization, who you are and what you do.  (Not to exceed one page)

2. List grants received from our foundation over the past 5 years, including amount and purpose:
   ________________  ________________________________________
   ________________  ________________________________________

3. Amount requested with this proposal: ________________

4. Purpose of the request: What are you hoping to accomplish?  (Not to exceed two pages)

Fiscal and Budget Information:  Submit an organization budget and a project budget (assuming it is a project for which you are applying) for the year to which this request pertains. Itemize by source and funder on both the organization budget and the project budget all funding committed (c) or pending (p) from each foundation, corporation/business, and government entity. If this request is for a start-up project, submit a first year start-up budget and a first full year projected budget.

Please note any significant change in funding your organization has experienced or is anticipating, (increase or decrease), and let us know the reason for the change.

Required Attachments:

1. Documentation of tax exempt status

2. Current Roster of the Board of Directors

3. For a renewal grant, submit a year-end one-page report on the previous grant received and the year received.

4. A copy of the last annual report, if available

5. An organization chart, if applicable

Allowed attachments, but not required:  Reports, copies of articles, or newsletters that describe your organization, or touts your work.

Miscellaneous:

1. Do not include a cover letter.

2. Proposal should be printed in readable size font (at least 12pt).

3. No 2-sided printed/copied pages

4. No delivery that requires a signature

5. No video, audiotapes, CD’s unless requested

Mail to:

Toni Rembe, President
van Loben Sels/RembeRock Foundation
131 Steuart St., Suite 301
San Francisco, CA 94105

If you have any questions or need clarification on any of the items listed above, please call Dan Corsello, E.D., at (415) 512-0572, or Gail Shuster, Program Administrator, at (415) 512-0500.

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