AED Grant Application Form
The La.-Miss.-W.Tenn. Kiwanis District Foundation offers a limited number of $500 grants each year to assist clubs with this District Project. Therefore, Kiwanis Clubs may only apply for one (1) AED Grant per Kiwanis Year.
This Grant Application is submitted by the Kiwanis Club of: For assistance with the purchase of an AED to be donated to:
I
, Club President, hereby certify that the following criteria have been met by our
Kiwanis Club, and respectfully request the District Foundation Board approve this AED Grant Application.
□ By official action of our club’s Board of Directors, approval to submit this request was taken at the Board Meeting held on ____/ ____/ 20____.
□ Our Kiwanis Club is in good standing with the District Foundation, having contributed at least $5 per member to the 2010-2011 Annual Gift Campaign, on ___/ ___/ 20___, in the amount of $_______. (Check # ____) An AED is being provided to the institution named above as outlined below:
□ An AED was purchased on ___/ ___/ 20___, for the institution. A copy of the invoice and proof of payment is enclosed with this application for verification for reimbursement. OR
□ An AED will be ordered for the institution within the next 90 days. A copy of the invoice or proof of payment will be forwarded to the District Foundation for reimbursement. NOTE: BOTH SIGNATURES REQUIRED: Signed:
on ___/ ___/ 20___ Club President
Date
Signed:
on ___/ ___/ 20___ Club Secretary
Date
President’s Name:
Secretary’s Name:
President’s Daytime Phone: (_____) _____________________
Secretary’s Daytime Phone: (_____) _____________________
For District Foundation only ~ Do not write in this box! AED Grant Application Received: ___/ ___/20____. Foundation Board Decision: Approved
Date of Decision: ___/ ___/20____.
Not approved
Date of Notification: ___/ ___/20____.
Grant Committee Member contact: ________________________________
Louisiana-Mississippi-West Tennessee Kiwanis District Foundation Kiwanis District Office Q5319-B Didesse Drive QBaton Rouge, LA 70808-6401 (225)769-9233 Q fax: (225)769-9215 Q [email protected]
This Grant Application is submitted by the Kiwanis Club of: For assistance with the purchase of an AED to be donated to:
I
, Club President, hereby certify that the following criteria have been met by our
Kiwanis Club, and respectfully request the District Foundation Board approve this AED Grant Application.
□ By official action of our club’s Board of Directors, approval to submit this request was taken at the Board Meeting held on ____/ ____/ 20____.
□ Our Kiwanis Club is in good standing with the District Foundation, having contributed at least $5 per member to the 2010-2011 Annual Gift Campaign, on ___/ ___/ 20___, in the amount of $_______. (Check # ____) An AED is being provided to the institution named above as outlined below:
□ An AED was purchased on ___/ ___/ 20___, for the institution. A copy of the invoice and proof of payment is enclosed with this application for verification for reimbursement. OR
□ An AED will be ordered for the institution within the next 90 days. A copy of the invoice or proof of payment will be forwarded to the District Foundation for reimbursement. NOTE: BOTH SIGNATURES REQUIRED: Signed:
on ___/ ___/ 20___ Club President
Date
Signed:
on ___/ ___/ 20___ Club Secretary
Date
President’s Name:
Secretary’s Name:
President’s Daytime Phone: (_____) _____________________
Secretary’s Daytime Phone: (_____) _____________________
For District Foundation only ~ Do not write in this box! AED Grant Application Received: ___/ ___/20____. Foundation Board Decision: Approved
Date of Decision: ___/ ___/20____.
Not approved
Date of Notification: ___/ ___/20____.
Grant Committee Member contact: ________________________________
Louisiana-Mississippi-West Tennessee Kiwanis District Foundation Kiwanis District Office Q5319-B Didesse Drive QBaton Rouge, LA 70808-6401 (225)769-9233 Q fax: (225)769-9215 Q [email protected]
