<p> National Greek Orthodox Ladies Philoptochos Society, Inc. Metropolis of Pittsburgh Greek Orthodox Ladies Philoptochos Society, Inc. National Children’s Medical Fund Grant Request Form This document seeks to explore your program, its history, track record and needs The deadline for electronic submittal of your grant request is Friday, May 31, 2013.</p><p>Eligibility Requirements: </p><p>In order to be eligible for consideration, all applicant organizations MUST:  Have current 501(c)(3) status from the Internal Revenue Service.  Be located in or serve populations of the Metropolis of Pittsburgh, which includes the state of Pennsylvania with the exception of Philadelphia and the surrounding area, the state of Ohio including only Northeast Ohio as far west as Rocky River and Central Ohio as far south as Columbus, and the state of West Virginia.  Address as their mission or project intent one of the Priority Issues for funding. Exclusions: </p><p>The CMF of the National Ladies Philoptochos Board will not consider requests for:</p><p> Direct grants, scholarships or loans for the benefit of specific individuals. Projects of organizations whose policies or practices discriminate on the basis of race, ethnic origin, sex, creed or sexual orientation. </p><p>Part I: Organization Information</p><p>Name of Organization: ______</p><p>Mailing Address: ______</p><p>City: ______State: ______Zip/Postal Code: ______</p><p>Phone Number: (_____) - ______</p><p>Fax Number: (_____) - ______</p><p>Website: ______</p><p>Primary Contact: ______</p><p>Title: ______</p><p>Primary Contact Phone Number: (____) - ______Primary Contact Fax Number: (____) - ______Primary Contact Email: ______</p><p>Part II: Mission Statement (Statement of Purpose)</p><p>What is the mission of your organization? ______</p><p>How would you describe your current constituencies? ______</p><p>Which geographical locations do you serve? ______</p><p>Who currently serves on your organization’s board? ______</p><p>Provide a brief history of your organization. ______Part III: Pertinent Statistics:</p><p>Total annual budget in the last completed fiscal year? ______</p><p>How many people did your organization serve last year? ______</p><p>Number of full-time employees does your organization employ? ______</p><p>Is your organization a 501(c)(3) public charity? Yes ____ No ____</p><p>If so, please provide your organization’s Employer Identification Number (EIN)? ______</p><p>Did your organization have an external financial audit conducted in the last fiscal year? Yes ____ No ______</p><p>Grant Request Information</p><p>Project/Program Title: ______</p><p>Project Description: (Comprehensively describe the purpose of the project or program. </p><p>What issues or needs will the CMF grant help your organization address? ______</p><p>What specific outcomes or deliverable do you plan to achieve with this project? ______</p><p>How will the funds be used? ______How many children and families people do you estimate this project/program will serve? ______</p><p>How would you describe the specific constituency this grant is designed to affect? ______</p><p>What is the total estimated budget/annual cost of this specific project or program? ______</p><p>What other grants have you received for this project or initiative? ______</p><p>Please provide us with an example of how your program has enhanced the life of a child, or will enhance the life of a child if put into place. ______</p><p>Please email, fax and/or mail this information to: Helen Lavorata Director, National Office Greek Orthodox Ladies Philoptochos Society, Inc. 126 East 37th Street New York, NY 10016 [email protected] (email) 212-977-7770 (office phone) 212-977-7784 (office fax)</p><p>If you have any questions, please contact: Mrs. Rosemary Nikas Metropolis of Pittsburgh Philoptochos President 87 Walker Road Canonsburg, PA 15317 [email protected] (email) 724-745-5799 (home phone) 724-263-9843 (cell phone)</p>