Beneficiary/Grant Application

Charity/not-for-profit organization name*

Address for grant to be issued*

Address Line 1

Address Line 2

City

State

ZIP Code

Contact name*

First Name

Last Name

Title*

Phone*

Email*

Website*

Top Executive and Title*

Board Members

Please list their names, companies and titles for each person listed.

Type of not-for-profit/501(c) or 501 (c)(3)*

Established date

Number of Tampa-area employees*

Please give a brief description of the organization’s impact on the Tampa Community and how you are helping to eliminate and/or bring awareness to the issue of Human Trafficking.*

Where do you anticipate the funds donated from the Light up the Night human trafficking awareness event going toward within your organization:*

(i.e. project, event, individual)