Date: / Date Incorporated:
Address: / Tax ID #:
Phone No. / City, State, ZIP:
ED Email address: / Website URL:
Executive Director:
Executive Director
NBLI Attendance: / Session 1 / Yes
No / Session 3 / Yes
No
Session 2 / Yes
No / Session 4 / Yes
No
Board Chair: / BC Address:
BC Email Address / City, State, ZIP:
Board Chair
NBLI Attendance: / Session 1 / Yes
No / Session 3 / Yes
No
Session 2 / Yes
No / Session 4 / Yes
No
Short Description of Project
Total Estimated Project Cost: / $
Request Amount: / $
Organizational Budget* / Revenue / Expenses / Surplus/(Deficit)
Current year
Previous year
2 years prior
3 years prior
*Refer to organization’s audited financials or completed 990 in reflecting revenue and expense in previous years. Current year’s figures can be based on budget forecast.
Populations Served
What percentage of the constituency you serve or represent could be classified as low-income?
%
What is the methodology used to determine the figure quoted above?
Check any that apply and indicate what percentage of your constituency, where appropriate.
Immigrants % Disabled % Terminal Illness %
Incarcerated % Seniors % Women %
History of abuse % Mental Illness % Substance Abuse %
LGBTI % Blind %
Infants (0-3) % Adults %
Children (3-12) % Elderly %
Teenage Youth (13-19) %
What is the total number of unduplicated individuals served or represented by your organization's programs and services in the past year?
Check any that apply and indicate what percentage of your Board, where appropriate.
Caucasian % Black or African American %
Latino or Hispanic % Asian or Asian American %
Native American % LGBTI %
Native Hawaiian/Other Pacific Isl. %
Women %
Other: ______% Disabled %
Check any that apply and indicate what percentage of your Senior Management, where appropriate.
Caucasian % Black or African American %
Latino or Hispanic % Asian or Asian American %
Native American % LGBTI %
Native Hawaiian/Other Pacific Isl. %
Women %
Other: ______% Disabled %
Mission of organization:
Overview of organization's history, programs and activities:
What are the organizational leadership goals that will be accomplished through this project? Please describe this project and indicate the circumstances that make this project a priority for your organization at this time?
How does this project relate to the best practices discussed during the NBLI?
What roles will the ED and Board Chair each play in the execution of this project? Who else will play critical roles?
If your project involves working with a consultant, please describe your selection process.
Please estimate the primary costs associated with the project and how grant funds would be used.
Please describe your organization’s capacity to implement your proposed project?
What is your process for assessing the outcome of this project?
Upload Project Proposal and a list of board members and their affiliations to the NBLI Drop Box
Questions: Contact us at 215-563-6417
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