Community Giving Application – North Country Hospital

Organization *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Tax Exempt ID# *

Website / URL *

Contact Person *

First

Last

Email *

One sentence description of project/program funded *

Amount Requested *

Date Funds Needed

It can take up to 60 days to process an application

How will you use this funding? *

How will you measure the success of this program? *

Describe how NCH support will be recognized or acknowledged:

File Upload

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