Polycom - Grant Assistance Request Form

Grant Assistance Request
Fields in Bold are required.
Name
Title
Organization
Organization Website
Email
Work Phone
Alternate/Cell Phone

Address

City, State, Zip
County
Country

Eligibility Questions

1. Are you a Nonprofit Organization, Government Entity, or Private Corporation?
	Yes No

2. Is your organization looking for assistance with a telecommunications project that will include video conferencing?
	Yes No

Organization Questions

1. What professional category best describes your organization?

If Other Please Describe:

2. In a brief paragraph, tell us about the mission of your organization, your primary customers, and primary service area(s).


Grant Needs

1. Briefly describe the project or program for which you are seeking grant funding assistance.


2. Have you applied for and received a federal or other grant in the past? If yes, please list the funding source(s)?
	Yes No
Source(s):

3. If you know the grant funding source(s) you would like to pursue, please list below.


Grant Resources

1. Will a grant application be supported by organizational leadership and partners. If so, how?
	Yes No
How?

2. Do you have any cash or in-kind matching funds or challenge grants that you can utilize to support the project? If 'Yes', please specify the funds amount.
	Yes No
Funds Amount

3. Please list all internal resources (i.e. staff, money) that you can contribute toward the preparation of the grant application.


4. Where did you hear about the Polycom Grant Assistance Program?

If Other Please Describe