C.To Foster the Most Protective Work Environment Possible Within the Construction Industry;

SECTION I

OVERVIEW

Job-Site Safety Institute (“JSI”) is a North Carolina non-profit corporation (501(c)(3) status pending). JSI is a research and educational organization dedicated to eliminating all job-site related injuries and deaths in the construction industry. JSI seeks to further this mission through receiving, administering and expending funds:

a.To protect the health and well-being of all persons involved in the construction industry andconstruction-related trades;

b.To promote worker safety by eliminating construction job-site injuries and fatalities through research, education, training and innovation in establishing best practices in the construction industry;

c.To foster the most protective work environment possible within the construction industry;

d.To develop collaborative relationships with local, state and federal labor departments as well as local, state and regional universities to encourage the exchange of ideas and technologies to better understand and mitigate the inherent risks and dangers within the construction industry;

e.To pursue strategic initiatives in partnership with insurance carriers; national, state and local building associations for enhanced research and development in support of job-site safety in the construction industry.

SECTION II

SUBMISSION REQUIREMENTS

Unless an alternate method for submission is indicated by JSI, please forward your grant submission for consideration, including any attachments, to the President of JSI at PO Box 97503 Raleigh, NC 27624.

General Requirements: Each application must include the following information in a grant proposal:

a.The JSI Grant Application Form;

b.An overview or background of the applicant, including a list of the Board of Directors and proof of tax-exempt status (if applicable);

c.A brief narrative description of the project;

d.An explanation of why the funds are needed;

e.Grants are intended to be in furtherance of the objectives of JSI and the grant application. Include information about how the grant proposal furthers one or more of the JSI objectives;

f.A detailed description of how any grant funding will be spent by the applicant, including a budget and explanation of all budget line items;

g.The objectives of the program proposed to be funded by the grant, including any measurable terms;

h.A description of how the applicant intends to evaluate the results of the project and the impact of the grant;

i.A description of the applicant’s staff involved in carrying out the project, including relevant qualifications and certifications;

j.The projected timetable for the project;

k.A description of how the JSI grant will be recognized;

l.An acknowledgement that the applicant will comply with the accounting requirements of JSI;

m.A statement that any grant proceeds awarded will be used only for charitable, educational or other 501(c)(3) permissible purposes in accordance with the mission and objectives of JSI; and

n.All submission and/or specific application requirements as may be set forth below.

SECTION III

TIMETABLE FOR GRANT APPROVAL

Unless otherwise specified by JSI, grant proposals may be submitted throughout the year and will be reviewed on or before the end of the calendar year after the proposal has been submitted. JSI reserves the right to request additional materials from the applicant while considering a grant proposal. An applicant should promptly respond to any request for additional information. Delay in providing any additional information will result in a delay in the final review of the proposal.

Grant recipients will be required to execute an agreement with JSI which details the terms and conditions of the grant, including expectations, reporting, site visit and accounting requirements and other responsibilities and obligations of the recipient.

SECTION IV

ACCOUNTING REQUIREMENTS

Grant funds may only be used in furtherance of the purposes for which the grant was given. Any Grant recipients are required to submit a full accounting how the grant funds were expended together with narrative report of the project. JSI should receive the narrative report within 12 months of the grantee’s receipt of the grant.

(Please attach this form as the first page of your completed application)

Legal Name of Grant Applicant:______

Contact Person:______

Address:______

Telephone Number:______Fax Number:______

Email Address:______

Website of Applicant:______

Project Title:______

Brief Description of Request:

Name of 501(c)(3) non-profit organization to which the check should be written or if a 501(c)(3) organization is not
available, list the person to whom the check should be written (the person designated will receive IRS Form 1099-MISC and will be responsible for any income taxes):

______

Amount of Grant Being Requested:______

Total Anticipated Cost of Project:______

Have you previously received a Grant from Job-Site Safety Institute?______

If yes, when:______

Amount of Grant:______

Name of Prior Project:______

Other Grants/Commitments Received for this Project:

Other Proposals/Grant Applications Pending for this Project:

I hereby certify that the information contained in this application is accurate and truthful. I understand that if a 501(c)(3) organization is not provided, that I am responsible for the payment of income taxes on the funds I may receive under the guidelines of the Internal Revenue Service. I understand that Job-Site Safety Institute strongly prefers that a 501(c)(3) organization be designated.

Signature:______Date:______