Community Giveback Form

Organization Information

Name of Organization*

Organization Website*

Organization Address*

Street Address Address Line 2 City State ZIP Code

Annual Operating Budget*

Are you a local chapter of a larger parent organization?*

Yes

No

Briefly describe your organization and the programs/services you provide:*

What is your mission statement?*

List any formal partnerships you have with other organizations:*

Which geographical area(s) do you serve?*

Please place the percentage of income you receive from each of the following sources:

Government Funds

Fees/Membership

United Way Funds

Corporate/Foundation Grants

Individual Donors

Special Events

Other

Applicant Information

You Name*

First Last

Your Email*

Phone*

How are you connected to this organization (board member, volunteer, employee, etc.)?*

Project Overview

How will this improve the community and your ability to continue your mission?*

Describe your specific construction needs.*

Briefly describe where you are in the process (architect selected/design complete, preliminary budget, timeline.*

If you need help with any or all of those items, please let us know here.

What is your budget?*

What is the timeline?*

Which of our services are you requesting?

Construction

Architecture & Design

Virtual Design & Construction

Healthcare Planning Services

Program Management

Does your organization own the land or building?

Yes

No

Identify any project partners (corporate sponsors, financial donor, in-kind partnerships)*

What is the expected return on investment for the community?*

Name of person from your organization who is responsible for leading this project.

First Last

Documentation

In this section we ask that you upload several different types of documents about your organization and project.

Please upload only PDFs, Microsoft Documents, or Text documents. You may upload more than one file within each section if needed.

Officers, Directors, and Staff Members

Please upload a list.

Max. file size: 300 MB.

A copy of your IRS 990/W9

Max. file size: 300 MB.

A copy of your 501 (C) 3 letter of tax exemption

Max. file size: 300 MB.

Any letters of support, in-kind donations and/or partnership agreements

Max. file size: 300 MB.

Any preliminary Design documents

Max. file size: 300 MB.

Any preliminary Budget documents

Max. file size: 300 MB.

Phone

This field is for validation purposes and should be left unchanged.

Tonn and Blank Construction Gives Back

Organization Information

Applicant Information

Project Overview

Documentation

Email

Toll Free Number

Fax Number

Headquarters

Indianapolis

Lafayette

Fort Wayne

Off-site Construction Division

Office Status