Altrusa International of Tampa
                   Wilma B. Hogan Foundation, Inc.
                                          P.O. Box 46396
                                Tampa, Florida 33646

                                     Grant Application

Date of Application:                                                    Amount Requested:

Name of Organization:

Address:


Executive Director:                                                       Phone Number:


Name and Title of Contact Person:                          Phone Number:


Tax Status   (     ) Charitable Organization 501-C3
                      (     )  Other - Please Specify

Date Organized:

Major goals and purpose:


Project for which funds are requested (Give purpose and objectives):


What are other sources of financial aid for the project?
(List other sources and amount applied for)


Does your organization receive Federal or other government funding?


Submitted by:
                                                                                                Received:
            Name:                                                                                Initials:
            Title:                                                                            Acknowledged:  
                                                                                                         Initials: