Prolacta Bioscience Corporate Giving

By completing this form you are affirmatively and voluntarily providing your personal information to Prolacta Bioscience, Inc. Your information will be processed for the purpose of review and evaluation of your application. For additional information about how we process your personal information, please visit https://www.prolacta.com/en/privacy-policy/.

Organization Information

Organization Legal Name, as it appears on your 501(c)(3) IRS determination letter*

Upload a copy of your 501(c)(3) IRS determination letter.*

Employer Identification Number (EIN)*

Organization Website

Street Address*

City*

State/Region*

Country/Region*

First Name*

Last Name*

Phone number*

Email*

Job Title*

Proposal

In 300 words or less, describe the organization’s mission.*

In 100 words or less, describe the geographic area this organization serves.*

In 500 words or less, describe the proposed project or program and state its needs.*

In 300 words or less, state the purpose of the fund request and how it relates to Prolacta Bioscience, Inc.*

In 200 words or less, explain how the impact and effectiveness of the funds requested would be measured, evaluated, and/or disseminated.*

Project Start Date*

Project End Date*

Funding Request Details

Total Budget for the Project*

Amount Requested from Prolacta Bioscience, Inc.

Please submit an estimated, itemized total budget. Include notations on how the funds will be used on your budget submission.

Are you willing to accept partial funding from Prolacta Bioscience, Inc.?*

Yes

Additional Secured Funding for this Project

Organization Name

Commitment Amount

Organization Name

Commitment Amount

Organization Name

Commitment Amount

Payment Contact (if different from Primary Contact)

Payment Contact Name

Payment Contact Email

Payment Contact Phone

Publicity Notice: If your organization is chosen as a recipient of funding, you, on behalf of your organization, grant to Prolacta Bioscience, Inc. ("Prolacta") and its promotional agents, express permission to use your organization’s name, location, purpose, logo or other images, and a description of the project that will be funded for promotional purposes, in any media now known or hereafter developed, without compensation. Even though you, on behalf of your organization, consent to all of the above, Prolacta has no obligation to undertake any of the activities or use any of the materials described therein.