^{GO! Grant Application}

(Please print this form)

Organization Name __________________________________________________

Address ___________________________________________________________

Contact Person for this proposal ______________________________________

Daytime Phone Number _____________________ Fax ____________________

E-mail _____________________________ Today's Date___________________

1. Is the organization chartered by NY State’s Board of Regents? Yes ___ No ___

2. Is the organization a:

___501C3 ___Branch of local government ___Other?_________________________

3. Annual Operating Budget: ___________________

4. Have you applied to the NYSCA Museum Program in the past? Yes ____ No ____

If so, date of last contract______________________________________________________

5. Provide a two-page description of your organization's mission and activities. Also detail what the grant participant will gain from the proposed travel, and how the experience will be integrated into work at your museum.

6. Please include the following:
A) Resume of individual participating
B) Information on the proposed training

7. Travel Budget:

A) Registration Fees $_______________
B) Accommodations $__________________
C) Travel (in-state only) $_____________ Mileage: ______ miles@__________ (Mileage rate not to exceed the current state rate)

Total $________________*

*If the total exceeds the GO! limit of $750, how will your organization support the remaining expenses?