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Applicant Name: _____________________________________ Assigned Number: _________
The Lee County Medical Society Alliance Foundation has always maintained a position of neutrality in our community. Over the years, we have made every effort to ensure that decisions and choices made by our organization maintained that balance and avoided the appearance of endorsing any side to an issue or organization, particularly where there are distinct differences, factually and emotionally. Information is provided as to past recipients to encourage our members to utilize the following goals in the selection process: 1) DIVERSITY among the applicants and previous recipients as to the NEED being addressed and the POPULATION being served, and; 2) The emphasis on giving funds to those organizations and projects which will have the greatest COMMUNITY IMPACT and touch the greatest number of lives as possible. Eligibility Checklist ELIGIBILITY ITEMS DISQUALIFYING ITEMS______ Postal Delivery _______________________________________________ ______ Postmark Date _______________________________________________ ______ Application Signed _______________________________________________ ______ Application Complete _______________________________________________ ______ Previous Donor/Sponsor * (MR) _____________________________________________________ Pass Through Foundation _______________________________________________ ______ Health Care System _______________________________________________ ______ Completion w/in 1 year _______________________________________________ ______ Lee County _______________________________________________ Attachments ______ Tax Status * (MR) _____________________________________________________ Board List _______________________________________________ ______ Project Budget _______________________________________________ ______ Prior Receipt of Funds Year _______________ Amount $_________________ Year _______________ Amount $_________________ Year _______________ Amount $_________________ Checklist completed and number assigned by: _______________________________________________ Signature Date
*(MR) – Applies to Major Recipient Only. |
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