Organization or Person(s) requesting funding:
Date of Request (mm/dd/yyyy):
Amount of Request:	$
Contact Person(s):
Address:
Phone Number:
Email:
Knights of Columbus Contact:
Brief description of Organization or Person(s):
Purpose of request and how the funds would be used (be detailed please):
Is this a Catholic organization?	Yes No
Have you received funding from this council previously?	Yes No
If Yes, when and what was the amount:	Date: $
Is this a one time request, and if not, what would be the frequency of solicitations?:
Which Counties and Dioceses will benefit?:
Are soliciting from other sources? If Yes, please describe:	Yes No
Name as it should appear on check:
Address to where the funds are to be delivered:
Any Special Instructions: