Date:
Name:
Address:
Phone Numbers: Day: ___________________ Eve:_____________________
Is it all right to leave a message about the Grant at the numbers above?
Day: _____ Yes _____ No
Evening: _____ Yes _____ No
Email Address:
Name of Group (if different):
Contact Person (for groups):
Signature: ________________________________________
Demographic Information (Optional, but is part of award criteria)
Do You/All Group Members define yourself as Lesbian? _____ YES _____ NO
Age(s):
Race(s):
Differently Abled: _____ YES _____ NO
Please describe:
Income(s):
_____$6,000 or less
_____$6,001 - $12,000
_____$12,001 - $18,000
_____$18,000 or more
Are you low income by choice? _____ YES _____ NO (Example: are you a student?)
Are you a past Lesbian Variety Show participant? _____ YES _____ NO
A. How much money are you requesting?______________________
B. How will this grant assist your artistic development? (No More than 1/2 page).
C. Please describe how you propose to use the grant monies to accomplish the above. (No More than 1/2 page)
D. How will the Lesbian Community benefit from you receiving this assistance? (No More than 1/2 page)
E. Please provide a detailed budget describing how you will use this money. Receipts will be required. A Variety Show performance, display, or product copy will be required if a grant is accepted when applicable. (No More than 1/2 page)
Please mail (via postal service) completed application with SASE to: