The Bingham Program - Online Application Form

In Maine more than half the homicides each year are the result of domestic violence.

- Dept. of Public Safety's yearly Crime in Maine reports

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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:

Phone/Fax:

Contact Detail	Contact Detail	Contact Detail	Contact Detail
Phone:		Fax:

Email:

Project Details:

Project Title:

Address:

(if same as organization address, click here)

Area of Interest:

Area of Interest	Area of Interest	Area of Interest
Health Professions	Community Health	Health Policy

Summary Proposal:

(150 words or less)

Amount Requested:

Project Budget:

Additional Information:

Field Description	Field Data
What was the organization's last FY budget?
What geographic Maine area does the project serve?</DIV>
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:

Field Description	Field Data
Trustees, Board, Steering Group, or Advisory Committee
Detailed Proposed Project Budget
Narrative Proposal
Any Additional Information (optional)