Application - Qlarant Foundation Application

Grant Application

The mission of the Qlarant Foundation (Qlarant) is to improve the health of individuals and communities. To achieve this goal, Qlarant Foundation provides charitable grants to eligible 501c3 organizations that align with our mission. We prioritize funding for grassroots organizations based on their project/program's potential to impact access to improved healthcare and human services through the use of specific, measurable outcomes.

General Information

Your Organization’s valid 501(c)(3) EIN.

Qlarant Foundation awards grants to Organizations that are active in Washington D.C., Georgia, Florida, Maryland or Texas. Is your organization active in one of these states?

What counties in your state does your Organization serve? Please list the state and the county (Example: "FL-Broward"). If your Organization's reach is statewide, enter the state (Example: "State of Florida"). Please list all applicable states and counties.

Name of your Organization.

Documentation confirming your Organization’s 501c3 status AND copies of your Organization’s audited financials will be required if your application moves to the final review round. Are you able to provide this documentation?

Your Organization's mission statement.

Word Count: (500 word maximum)

Name of your Organization's CEO/President.

Street Address for your Organization.

Street Address 2 for your Organization.

City for your Organization.

State for your Organization.

Zip Code for your Organization.

Your Organization's website address.

First Name for your Organization’s Primary Contact Person.

Last Name for your Organization’s Primary Contact Person.

Phone Number for your Organization’s Primary Contact Person.

Email Address for your Organization’s Primary Contact Person.

Proposal Information

Name of the Program your Organization is requesting funding for.

What is the purpose of the Program your Organization is requesting funding for? Give a brief description and explain how the Program fits into Qlarant's Mission.

Word Count: (500 word maximum)

Dollar Amount your Organization is requesting.

Specific, measurable GOALS are required. Please state three or four GOALS that the Program intends to meet in the grant funding year.

Word Count: (500 word maximum)

If portions of the Program are to be funded by other sources, please list those sources of additional funding.

Word Count: (500 word maximum)

Who does/will the Program serve? How many individuals does/will the Program reach?

Word Count: (500 word maximum)

Provide a detailed budget for the Program that your Organization is requesting funding for. How would grant monies be spent? Sample Budget

Word Count: (500 word maximum)

How will your Organization sustain the Program beyond the one-year term of a grant from Qlarant Foundation?

Word Count: (500 word maximum)

Organization Information

Summarize your Organization’s history and state why it is uniquely qualified and best positioned to implement the Program you are requesting funding for.

Word Count: (500 word maximum)

List your Organization’s primary programs and activities.

Word Count: (500 word maximum)

List your Organization’s accomplishments.

Word Count: (500 word maximum)

List your Organization’s key personnel, including the number of staff and their job titles.

Word Count: (500 word maximum)

How does your Organization utilize volunteers?

Word Count: (500 word maximum)

How long has your Organization’s Executive Director been in place and briefly state his/her job history and education.

Word Count: (500 word maximum)

List your Organization's Officers and Directors.

Word Count: (500 word maximum)

Identify your status as an Applicant to Qlarant Foundation. New Applicant? Returning Applicant? Returning Grantee?

Does your Organization (employees, volunteers or leadership) have any personal or professional relationship with any Qlarant or Qlarant Foundation board member or employee? Please explain in detail below. If none, please type NONE.

By entering your name below you are attesting that the information in this application is accurate to the best of your knowledge.