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Workshop

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Community Grants Application | |
| Organization Information |
| Disclaimer |
| | | |
| Bristol-Myers Squibb Charitable Giving is not connected to or conditioned upon the prescription, purchase or recommendation |
|of any Bristol-Myers Squibb product or products by any person or entity. Please be advised that decisions regarding Charitable |
|Giving are made by a Charitable Giving Committee. Any communication from any person other than an approved representative of the |
|Charitable Giving Committee regarding a request or proposal for Charitable Giving, including, but not limited to, a commitment of|
|funds, is not authorized or binding upon Bristol-Myers Squibb. |
| |
|Bristol-Myers Squibb will generally process requests in the order in which completed applications are received. To ensure prompt |
|processing of your request, please make sure that all questions are completed and all supplementary materials are provided. |
|Requests are generally processed within eight to twelve (8 - 12) weeks of receiving a completed application and all required |
|supplementary materials. PLEASE BE AWARE, HOWEVER, THAT BRISTOL-MYERS SQUIBB DOES NOT COMMIT TO PROCESS ANY REQUEST WITHIN ANY |
|SPECIFIC TIME PERIOD. To maximize our ability to process your grant request within your required time frame, please submit your |
|request as early as possible. |
| | | |
| |Applicant Organization Name: | |
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| |Address: | |
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| |City: | |
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| |State: | |
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| |Zip Code: | |
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| |Country: | |
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| |World Wide Web Address (if any): | |
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| |US Federal Tax ID: | |
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| |Please classify your organization: | |
| |[pic] | |
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| |Please provide a description of the charitable organization and its charitable mission or purpose. | |
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| |Are there any other organizations or companies working in partnership with your organization to implement the program or | |
| |event for which you are seeking funding? | |
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| |If the applicant is a subsidiary of, affiliated with, owned by, or under the legal control of another entity (parent), please| |
| |give the full legal name of the highest level parent entity. | |
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| Number of Employees: |
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| |Paid Full Time: | |
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| |Paid Part Time: | |
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| |Volunteers: | |
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| Contact Information |
| Please provide the primary contact information for this request for funding. Be advised that all related correspondence |
|including payment, if your request is approved, will be sent to the contact provided below. |
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| |Prefix: | |
| |[pic] | |
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| |First Name: | |
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| |Middle Initial: | |
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| |Last Name: | |
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| |Suffix: | |
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| |Title: | |
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| |E-mail Address: | |
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| |Office Phone: | |
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| |Office Fax: | |
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| |Office Street Address: | |
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| |Office City: | |
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| |Office State: | |
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| |Office Zip Code: | |
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| |Office Country: | |
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| Proposal Information |
| |Only one selection can be made from drop-down menus. Please choose the most appropriate selection. Please attach additional | |
| |information as necessary at the end of this application. | |
| | | |
| |Start Date for Funding Cycle: | |
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| |End Date for Funding Cycle: | |
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| |Grant Title: | |
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| | | |
| |Amount Requested from Bristol-Myers Squibb: | |
| |Please round to the nearest dollar. | |
| | | |
| | | |
| |Total Funding Sought: | |
| |Total amount of funds that organization seeks to raise from all sources, including Bristol-Myers Squibb, related to this | |
| |funding request. | |
| | | |
| | | |
| |Program Type: | |
| |[pic] | |
| | | |
| |Please provide the dollar amount of this grant request that can be considered a Charitable Donation. | |
| | | |
| | | |
| |Please provide the dollar amount of this grant request that cannot be considered a Charitable Donation. | |
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| | | |
| |Please provide the percentage of this grant request that can be considered a Charitable Donation. | |
| |NOTE: The sum of the percentage for this question added to the percentage from the next question, should not exceed 100% | |
| | | |
| | | |
| |Please provide the percentage of this grant request that cannot be considered a Charitable Donation. | |
| |NOTE: The sum of the percentage for this question added to the percentage from the previous question, should not exceed 100% | |
| | | |
| | | |
| |Type of Support: | |
| | | |
| | | |
| |Location of Organization or Fundraising Campaign/Event: | |
| |[pic] | |
| | | |
| |Geographical Area Served: | |
| |[pic] | |
| | | |
| |Therapeutic Area of Focus: | |
| |If not healthcare related, please select "Not Applicable" from the drop-down list | |
| |[pic] | |
| | | |
| |Primary population your organization serves: | |
| |[pic] | |
| | | |
| |Describe the purpose of the fundraising effort and explain how donations will specifically be used to further your | |
| |organization's charitable purposes or mission. If you are seeking a contribution through an event such as a fundraising | |
| |dinner or activity please include a description of the event in detail, including sponsorship levels if applicable. | |
| | | |
| | | |
| |Describe the measurable outcomes you expect to result from your organization's programs/activities to be funded by the | |
| |proposed donation: | |
| | | |
| | | |
| |Describe how you plan to evaluate success of outcomes which result from your organization's programs/activities to be funded | |
| |by the proposed donation: | |
| | | |
| | | |
| |Describe, if applicable, plans to report results, to build capacity, and/or for replication from or of your organization's | |
| |programs/activities to be funded by the proposed donation. | |
| | | |
| | | |
| |Provide the estimated number of individuals who will benefit from your organization's programs/activities to be funded by the| |
| |proposed donation: | |
| | | |
| | | |
| |Please indicate whether this request is part of a general fundraising effort targeting other potential donors and the total | |
| |amount of funds that the organization has already secured relating to this funding request. | |
| | | |
| | | |
| |Describe any complimentary exhibit or attendance offerings, including, if applicable, location and date: | |
| |Approval of this grant is not connected to or conditioned upon complimentary attendance or exhibit space. This box is for | |
| |planning and logistics only and will not be used by the US Charitable Giving Committee in any way to determine whether or not| |
| |to fund your program or activity. | |
| | | |
| | | |…...

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