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County of Hawai` i Nonprofit Grant Application FY2019-20 <br />Agency Name: <br />Program Name: <br />Agency Director: Phone No.: } — <br />Contact Person: Phone No.: ( } — <br />Mailing Address: Address: <br />Address: <br />City, ST, Zip <br />Facility Address: Address: <br />Address: <br />City, ST, Zip <br />Email Address: <br />Accou ntant/CPA: <br />Firm {if applicable}: <br />Fax No.: ( } <br />Phone No.: <br />Mailing Address: Address: <br />Address: <br />City, ST, Zip <br />YOU ARE RESPONSIBLE TO KEEP TIE ABOVE INFORMATION CURRENT AND TO <br />PROMPTLY NOTIFY T14E FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES <br />Amount of Request for County Nonprofit Grant Program Funds: <br />Geographical Areas To Be Served. (One or more can be checked) <br />❑ Puna ❑ Hamakua ❑ North Kona <br />❑ South Hilo ❑ North Kohala ❑ South Kona <br />❑ North Hilo ❑ South Kohala ❑ Ka`u <br />Services or Activities To Be Provided: (One or more can be checked) <br />❑ Educational concerns ❑ Youth ❑ Victims of Crimes <br />❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises <br />❑-1 Needs of the poor ❑ Physical/Emotional Disabilities <br />Public Health and Welfare of the People and the Environment <br />EXHIBIT A <br />NONPROFIT GRANT APPLICATION Fri 2019 s 2020 Page I of 8 <br />