Appendix F Consortium Form.pdf

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Review of NEA Data Collection Tools & Performance Measurements
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NEARFP10-04
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Grants for Arts Projects Application Consortium Partner Information (For official Consortium Applications only)

Read the instructions for this form before you start.

OMB No. 3135-0112 Expires 11/30/07

To be completed only by the one primary consortium partner and included in the application package. Do not complete this form if you are applying for a Challenge America Fast-Track Review Grant.

Lead Applicant for Consortium (official IRS name):

Primary Consortium Partner’s IRS name:

Popular name (if different):

Primary Consortium Partner’s Authorizing Official

Mr. Ms. First: Last:

Address:

City/State/Zip Code (9-digit number):

Taxpayer ID Number (9-digit number):

Web Address: http://

Contact: Mr. Ms. First: Last:

Title:

E-mail:

Telephone:

ext.

Fax:

Organization’s Total Operating Expenses for the most recently completed fiscal year (unaudited figures are acceptable): $

Mission/purpose of your organization:

Briefly describe your organization’s involvement in planning and executing the consortium project including programming, management, finances, and any responsibilities for matching the Arts Endowment’s grant. Be specific; do not provide a general statement of support for the project. Use this space only.

Applicant name:
Partner's name:
Partner's popular name:
Partner: Mr: Off
Partner: Ms: Off
Partner First name:
Partner Last name:
Street address:
City/state/zip:
Partner Tax ID 1:
Partner Tax ID 2:
Partner Web address:
Contact: Mr: Off
Contact: Ms: Off
Contact First name:
Contact Last name:
Contact Title:
Contact email:
Contact Area Code:
Contact Phone number:
Contact Phone extension:
Contact Fax Area Code:
Contact Fax number:
Total organizational operating expenses for the most recently completed fiscal year::
Partner Mission:
Project involvement:

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