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Rev. 01/22
VNA Foundation, Inc.
1180 Spring Centre S Boulevard, Suite 304
Altamonte Springs, Florida 32714
Agency Name:________________________________________________________
Address:_____________________________________________________________
_____________________________________________________________________
Telephone: ____________________________________________________________
Proposal Request:______________________________________________________
Designated Spokesperson: ______________________________________________
Alternate Spokesperson:_________________________________________________
Statement of Agreement:
We agree to furnish a report on expenses related to products and services funded by the grant. We accept the terms and conditions set out in Exhibit A of the VNA Foundation, Inc. Grants Policies and Procedures Statement, attached hereto.
Authorization:
Our signatures acknowledge that the information contained in this funding proposal may be shared with other funders. In addition, this certifies that this request is consistent with our organization’s Mission/Articles of Incorporation and Bylaws and has been approved by a majority of the Board of Directors on (date):
_________________________________________
Statement of Certification:
We certify that the 501(c)(3) status for __________________________________ has not been revoked or modified since creation of the attachment.
_____________________________________ ________________________________________
Typed Name of Agency Administrator Typed Name of Board Officer
____________________________________ ________________________________________
Signature Signature
____________________________________ ________________________________________
Date: Date:
Rev. 03/03