Grant Application * denotes a required field. Date Grant request is needed by: * example: 10/10/2012 Type of assistance requested: Community Participation Grants Instructional Grants Organization Membership Grants Sports Grants Hobby Grants Music Grants Apparel Grants Food Grants Personal Hygiene Grants Parent Rest & Relaxation Grants Technology Grants Describe how will the request benefit the applicant: * Name of applicant: * Address: * City: * State: * Zip Code: * Telephone Number: * example: (330)555-1234 E-mail: Where does applicant reside: Family Home Residential Facility Other Name of person filling out application: * Address: * City: * State: * Zip Code: * Telephone Number: * example: (330)555-1234 E-mail: Relationship to applicant: *

3581 Youngstown-Warren Rd. (Rt. 422) | Warren, OH 44484 (near United Way) | P: 330.469.5444 | F: 330.469.5440 1240 North Main Street | Niles, OH 44446 | P: 330.349.4595 | F: 330.349.4592 | info@thenicholsoncenter.com © 2010 The Nicholson Center. All Rights Reserved. | Developed by Cassidy Advertising & Consulting LLC | Powered by Belstar Media