URLThis field is for validation purposes and should be left unchanged.Name of Organization(Required)Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Contact Person(Required) First Name Last Name Work Phone Number(Required)Home Phone NumberIs organization requesting funding exempt from payment of income tax?(Required) Yes No If yes, a copy of letter (Form 501(c)(3)) from IRS must be attached:(Required) Drop files here or Select files Max. file size: 499 MB. Is a copy of financial statement(s) attached?(Required) Yes No Has this organization previously received funding from Operation Roundup?(Required) Yes No if yes, list the date(s) and amount(s) of funds received(Required)Describe the purpose of the funds being requested. Include amount requested and specifics of how the funds will be used.(Required)List other sources of funding being used for the purpose(s) described above.(Required)Do you or your organization have a business and/or family relationship with any person who serves on the board of trustees for the Ouachita Electric Cooperative Trust? If so, describe any such relationship(s).Applicant ConsentI understand that the information contained in this application is for the purpose of obtaining funding from the Ouachita Electric Cooperative Trust on behalf of the undersigned organization. Each undersigned understands that the information provided herein is used in deciding grant funding, and each undersigned represents and warrants that the information provided is true and complete and that the Ouachita Electric Cooperative Trust may consider this statement as continuing to be true and correct until a written notice of change is provided. The Ouachita Electric Cooperative Trust is authorized to make all inquiries they deem necessary to verify the accuracy of the statements make herein. The undersigned hereby agrees to provide documentation for the expenditure of any funds received from the Ouachita Electric Cooperative Trust within 30 days of receipt of the funds. I hereby verify the information to be true and complete and agree to the terms and conditions. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature.Name of Organization(Required)Representatives Electronic Signature (Full Name)(Required)
