City of Williamsport
2007 Cultural Grant

Application Form
   (Submit 6 Copies of Entire Application)

Name of Organization:____________________________________________________________

Address:________________________________________________________________

City: Williamsport        State: PA       Zip: ______________________

Contact Person: __________________________         Title: ________________________

Phone (home): __________________________             (work) _______________________

Fax No: ________________________________            E-mail: _______________________

Grant Amount Requested: $___________________    Project Date(s):________________
    (may not exceed $1,500)

Project Name:_____________________________________________________________

Federal ID#: _________________________________________

Certification and Statement of Assurances

To be signed by the person authorized to submit the application on behalf of the
applicant organization:

The application certifies that (1) the information contained in this application is truthful
and correct;
(2) the funds, if granted, will be used only for the purpose described in this application;
and
(3) the applicant will comply in all respects with the guidelines for this grant and
acknowledges that the failure to do so may necessitate the repayment of all grant funds.

Signature:________________________________    Date: ________________________

Typed Name: _____________________________    Title: _________________________