Foundation Request Form

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Please fill out the following form for any Foundation Requests.

Note: AgVA Foundation reserves the right to publicly disseminate information about this contribution in its newsletters and other promotional materials.

Applicant's Address*

If 501(C)(3) please attach documention.:

Provide a Brief Overview of Applicant Organization

Please provide a description of the specific activities for which the funds will be used and explain how the proposed activity will meet one or more of the following “focuses” of the AgVA Foundation:
• Programs that meet nutritional, educational or leadership needs of rural youth;
• Mentoring, training and other programs for young and beginning farmers;
• Continuing education and training for existing farmers;
• Local events in rural communities that promote agriculture or local foods; and,
• Agricultural entrepreneurship education and training.*

Please provide a "Sources and Uses of Funds Statement" that includes all revenue and expenses for the proposal*

Please explain measures that will be taken to assure that the activity is carried out effectively, on time and within budget. Please include a timeline of major events or activities that are to occur.*

Explain how the applicant will "complement" the work of other organizations in the area instead of competing against them.*

If applicable, explain how the program or activity will be self-sustaining after grant period has ended.* (Please include timeline)

Please provide the names and a short biography of each of the applicant's management and executive officers.*

Please provide the names of each of the applicant's board of director's members.*

Explain how you will provide recognition to AgVA Foundation for this grant, e.g. press release(s), promotional pieces, recognition in program, speaker or introduction of a speaker, event booth, etc.*

By signing below I affirm that to the best of my knowledge that the information contained in this application and any attachments, exhibits or appendices included herein is accurate and truthful. I also assure that I am authorized to sign this document for the applicant.

Signature here

Note: AgVA Foundation reserves the right to publicly disseminate information about this contribution in its newsletter and other promotional materials.

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