Committee is chaired by the Treasurer. Two (2) copies of Submit by Governing to : *Include Board’s One (1) county and strategic plan Grant One (1) of program type Application and each policy, in subject including sustainability only if line. Include signatures and amended: plan. all a clear conflict of attachments attachment interest, in a single GRANT APPLICANT INFORMATION title (e.g. confidentiality, email. Wake DV Organization type: Nonprofit Corporation Local Governmental Entity Grant DUNS # if applicable (Data Universal Numbering System): Application). organizational Organization’s fiscal year: January - December July - June October September – code of Year the organization was incorporated: conduct, Year the organization obtained nonprofit status: internal For how many has the organization received grant funds from NCCFW/YI? controls, recordkeeping Month and year DV or SA program began operations: (for electronic Is program a subsidiary of another organization? Yes No and manual Current Executive Director: As of files), and Name: whistleblower. E-mail Address: Identify each Telephone Number: policy clearly Current Program Director (if applicable): As of in attachment Name: titles. Please E-mail Address: note: The Telephone Number: NCCFW/YI Administrative Office Physical Address: does not accept Mailing Address (if different from responsibility Days and Hours of Operation: for the Administrative/Business Line Phone: Fax: sufficiency or DV or SA Shelter/Program Physical Address (optional): the legality of Mailing Address (if different from the policies Days and Hours of Operation: submitted. Program Office/Facility Phone: Fax: Crisis Line: Sample policy Organizational Website Address: templates are Please indicate if the agency providing program services funded by the NCCFW/YI: available in Owns the property where services will be provided: Yes No the Grants Leases space where services will be provided: Yes No section of the NCCFW/YI Utilizes donated space where services will be provided: Yes No website. Does your program multi-lingual services? Yes No
Committee is chaired by the Treasurer. Two (2) copies of Governing Board’s strategic plan and sustainability plan. Submit by to : *Include county and program type in subject line. Include all attachments in a single email. One (1) Grant Application including signatures and a clear attachment title (e.g. Wake DV Grant Application). One (1) of each policy, only if amended: conflict of interest, confidentiality, organizational code of conduct, internal controls, recordkeeping (for electronic and manual files), and whistleblower. Identify each policy clearly in attachment titles. Please note: The NCCFW/YI does not accept responsibility for the sufficiency or the legality of the policies submitted. Sample policy templates are available in the Grants section of the NCCFW/YI website. GRANT APPLICANT INFORMATION Organization type: Nonprofit Corporation Local Governmental Entity DUNS # if applicable (Data Universal Numbering System): Organization’s fiscal year: January - December July - June October – September Year the organization was incorporated: Year the organization obtained nonprofit status: For how many has the organization received grant funds from NCCFW/YI? Month and year DV or SA program began operations: Is program a subsidiary of another organization? Yes No Current Executive Director: As of Name: E-mail Address: Telephone Number: Current Program Director (if applicable): As of Name: E-mail Address: Telephone Number: Administrative Office Physical Address: Mailing Address (if different from Days and Hours of Operation: Administrative/Business Line Phone: Fax: DV or SA Shelter/Program Physical Address (optional): Mailing Address (if different from Days and Hours of Operation: Program Office/Facility Phone: Fax: Crisis Line: Organizational Website Address: Please indicate if the agency providing program services funded by the NCCFW/YI: Owns the property where services will be provided: Yes No Leases space where services will be provided: Yes No Utilizes donated space where services will be provided: Yes No Does your program multi-lingual services? Yes No