<p> Rotary Club of Smyrna Application for Rotary Partnership P.O. Box 353 Smyrna, Tennessee Service above37167 Self—He Profits Most Who Serves Best</p><p>Ginny Williams, President </p><p>□ Completed application (no partially completed applications will be accepted)</p><p>□ Current list of agency’s Board of Directors</p><p>□ Letter of IRS determination of Tax-Exempt Status 501(c)(3) </p><p>□ Agency’s latest audit and management letter of year-end balance sheet and statement of activity, if agency is not audited </p><p>□ Most recent balance sheet, statement of activity and budget to actual</p><p>□ List of partner organizations</p><p>□ Certificate of insurance indicating general liability coverage of all volunteers, if applicable</p><p>We invite your application and look forward to working with you. If you need more information, have questions or would like to obtain a Word form of this document, please visit our web site at www.rotaryofsmyrna.org For Office Use Only Rotary Club of Approved □Yes □ No Date______Amount $______Smyrna P.O. Box 353 Amount Paid: $______Smyrna, Tennessee Date Paid ______Check # ______</p><p>______Organization/Agency Name</p><p>______Contact Person Telephone E-Mail Address</p><p>______Street Address/Post Office Box City State/Zip</p><p>______Home Phone Work Phone Mobile Phone</p><p>______Internet site address Fax Number</p><p>Have you previously received funds from the Rotary Club of Smyrna? □Yes □No If yes, please list and include disclosure of those expenditures:</p><p>Date Amount Date Amount</p><p>______</p><p>______</p><p>______</p><p>Is your organization/agency exempt from payment of income tax? □Yes □No If yes, a copy of form 501(c)(3) from Internal Revenue Service AND either a Form 990 or a Financial Statement must be attached.</p><p>Primary funding agency of applicant. List source(s) from which you already receive revenue.</p><p>______</p><p>______</p><p>______</p><p>Is your organization/agency currently located in the Middle TN area? □Yes □No</p><p>When will these funds be needed? What is the timeline for this project? ______</p><p>Please briefly summarize your past and present affiliation, if any, with the Rotary Club of Smyrna, including the names of any member of your organization/agency who is also affiliated or a member.</p><p>______</p><p>______</p><p>State purpose of request. List specifically how funding will be utilized with full description of your need; how this need came about; how it will benefit your clients/program; and how will you determine whether these funds have achieved its goals. (Attach additional sheets if necessary.)</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>Estimated total amount needed for project: $______</p><p>Totals from other funding sources: $______</p><p>Total requested from Smyrna Rotary Club $______</p><p>The information contained in this statement is for the purpose of obtaining funding from the Rotary Club of Smyrna on behalf of the undersigned. Each undersigned understands that the information provided herein is used in deciding to grant funding, and each undersigned represents and warrants that the information provided is true and complete and the Rotary Club of Smyrna may consider this statement as continuing to be true and correct until a written notice of change is provided. Rotary Club of Smyrna is authorized to make all inquiries they deem necessary to verify the accuracy of the statements made herein.</p><p>Signature of Representative ______</p><p>Title of Representative ______</p><p>Date ______</p><p>Rotary Club of Smyrna P.O. Box 353 Service above Self—He Profits Smyrna, Tennessee Most Who Serves Best 37167 </p>