<p> Birmingham Rotary Club Endowment Fund, Inc.</p><p>Request for Funding – 2011 / 2012 Fiscal Year</p><p>Instructions: please fill out the form below, providing as much detail as possible. You may submit additional attachments, as you feel necessary. Submittal may be by mail, in person or as an attachment to e-mail. The Birmingham Rotary Club Endowment Board will review and make decisions on the disbursement of funds three (3) times during the fiscal year. </p><p>Please note: the Endowment Fund policy is such that an organization may request and be awarded a grant for three years in a row. You may not request a grant for the 4th consecutive year. There is a one year “sit-out” period before we will entertain a new funding request.</p><p>Submittal deadlines: November 1, 2011 / February 1, 2012 / May 1, 2012.</p><p>BOARD ACTION USE ONLY Mail: Birmingham Community House date requested – Attn: Birmingham Rotary Club Endowment Board Ms. Adwenia Roy, Vice President date approved – 380 South Bates Street Birmingham, MI 48009 amount requested – amount approved – </p><p>EMail: [email protected] funds from – (restricted / lasting impact)</p><p>If applicable, Name of Rotarian submitting request: ______</p><p>Date of Submittal: Name of Organization Requesting Funds (also list “payee” if different):</p><p>Street Address: </p><p>City: State: Zip: Contact Person: </p><p>Telephone #: Fax #: Email: Website: </p><p>Funding Request Amount: </p><p>Is this request tied to a specific event date? Yes No If Yes, include information in description section. Are there any matching funds being provided? Yes No If Yes, include information in description section. What percent of the overall funding need does this request represent? </p><p>Description of Request: (Please describe for Who, What, When, Where, Why, How) Attach additional pages or materials as necessary. If emailing photos – please use jpeg files as attachments.</p><p>______Page 2</p>