Online Nomination Form

Name of Organization

Mailing Address

Exempt Organization Tax #

Contact Name/Title

Phone

Website

Approximate year formed

Describe the organization’s services provided to residents of Fulton, Montgomery or Schoharie Counties

What is the approximate annual budget?

Sources of Income (Please attach annual budget document)

Approximately what percentage of income goes to administrative costs vs direct services

Describe how the funds received would be used

Name of Nominating Member

Member Email

Member Phone

Date

Additional Info and Comments