Name of Organization ________________________________________________________
Official Address ____________________________________________________________
City _______________________ State ____ Zip _________
Office Telephone _______________________ Office Email Address___________________
Name of Program Director _______________________ Telephone ____________________
Email Address of Program Director______________________________________________
I certify that the information contained in this application is true and complete. I understand that a fraudulent representation or omission of any information requested is grounds for immediate refusal to grant assistance under this program.
I understand that the awarding of the Grant is neither a right nor entitlement and that the Board of Directors of the CPC Foundation shall have sole discretion in determining whether this organization is qualified to receive a Grant.
Signed ________________________________ Title_________________ Date______________
Form Part I: Application 73009
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