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Please complete all sections of this application. Incomplete applications will be returned to the applicant, which may result in processing delays. Please allow 30 days following the due date for grant notification.

Community Assistance Application

Today's Date:*
Community Assistance Start Date*
Community Assistance Program*
Name:*
Address:*
E-mail*
Home Phone*
-

Encompass Relationship Status

Encompass Employee?*
Type of Employee
Office Location
Department
Position
Years of Employment
Hours per Week
Encompass Retiree?*
Last Job Title
Years of Employment.
Community Partner?*
Relationship

Sponsoring Organization

Name of organization?*
Contact Person
Contact Address*
Contact Phone:
-
Fax
-

Financial Need

Total grant request*

Proposal Summary

Please describe what the funds would be used for in narrative format.
How did you hear about Encompass Cares?