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Home • Online Application Form
Online Application Form
Fill out the following online application form and submit with your proposal and attachments. After clicking on the "submit" button, you will be sent to a Web page detailing the information that you entered that you may print for your records. You will receive confirmation of receipt by email.

Contact Information:
Contact Name:
Organization:
Address:
Line 1: 
Line 2: 
City:
State:
Zip:
Phone/Fax:
Phone:
Fax:
Email:
Project Details:
Project Title:
Address:
(if same as organization address, click here)
Line 1: 
Line 2: 
City:
State:
Zip:
Area of Interest:
Health Professions
Community Health
Health Policy
Summary Proposal:
(150 words or less)
Amount Requested:
Project Budget:
Additional Information:
What was the organization's last FY budget?
What geographic Maine area does the project serve?
Does the organization have 501(c)(3) tax status?
Yes    No
If not, name of 501(c)(3) fiscal sponsor:
Has The Bingham Program ever funded your organization?
Yes    No
If yes, most recent year:
Please List:
Trustees, Board, Steering Group, or Advisory Committee
Detailed Proposed Project Budget
Narrative Proposal
Any Additional Information (optional)

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