Organization Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact Person *

(if applicable)

First Name

Last Name

Phone

(###)

###

####

Is your organization a prior recipient of grant money from 3.21 for Life? *

Yes

No

Upon receipt of grant funds, 3.21 For Life would like your commitment of quarterly check-ins, correspondence and photos to use on our social media platforms to promote both your organization and ours.

Do you agree to the terms as stated above?

Yes

No