Thank you for considering the FLTA Charitable Action Foundation as a partner to support your nominated organization. Please complete the below information for your community organization to be considered as a candidate to receive funds of support. If you have additional information that should be considered and it will not fit in the below, please email the information to Jena@FLTA.org.

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* 1. For Questions 1 - 6: Your Contact Information

Your Name

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* 2. Your Company

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* 3. Is your company a member of the Florida Land Title Association?
You do not have to be an FLTA member to submit an application.

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* 4. Your Job Title

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* 5. Your Phone

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* 6. Your Email

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* 7. For Questions 7 - 15: Nominating Organization Contact Information

Please provide complete contact information for the organization you are nominating for a grant: Organization Name

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* 8. Organization Address (Street, City, State, and Zip):

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* 9. Organization Web Address:*

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* 10. Is this organization a local chapter of a national organization? For example, a local chapter of Habitat for Humanity.

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* 11. Organization Contact Person

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* 12. Contact Phone* (If there isn’t a contact person, please include the organization’s main phone number)

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* 13. Contact Email* If there isn’t a contact person, please include the organization’s main email)

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* 14. Has the organization received a grant from the FLTA Charitable Foundation?

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* 15. If yes, what year was the grant given? and what was the amount?

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* 16. For Questions 16 - 24: Nominating Organization Details

Please provide information about the organization you are nominating for a grant. This will be used to evaluate whether the organization is aligned with the mission of the FLTA Charitable Action Foundation.

Mission
Please provide the organization’s mission.

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* 17. 501(c)3 Status - Please provide the organization’s Federal Employer Identification Number (EIN) or Tax Identification Number. This is usually available on an organization’s website or the W-9 form.

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* 18. How does the organization relate to the FLTA Charitable Action Foundation’s values?
Please describe how the organization exemplifies supporting Florida Communities, and Housing Resiliency and Security.

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* 19. Why do you support the organization?
Please describe why you support this organization and why the FLTA Charitable Action Foundation should support it. The FLTA Charitable Action Foundation will give preference to organizations related to supporting Florida Communities, and Housing Resiliency and Security.

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* 20. How do you support the organization?
Please describe how you or your company have supported the organization within the last 5 years (e.g. volunteering, donating money, donating goods, etc.). An individual’s level of engagement with the organization is an important consideration during the application review, so please make sure to highlight your engagement!

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* 21. How does the organization impact your local Florida community?
Please describe how the organization has specifically made an impact on your local Florida community.

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* 22. Additional Information
Please share any other general information you think we should know about the organization (e.g. region/location served, chapter of national organization, operating budget, average annual fundraising total, etc.).

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* 23. I hereby grant full permission to the FLTA Charitable Action Foundation and its representatives, affiliates, or subsidiaries to use, reproduce, publish, distribute, and exhibit my name, picture, portrait, biographical information, likeness or voice, and any statements, quotes or testimonials provided by me (collectively, “My Likeness”) in connection to FLTA Charitable Action Foundation and this grant application.

I acknowledge that the FLTA Charitable Action Foundation owns all rights to the images and recordings in any medium, including but not limited to print media and electronic media (including websites, social media, etc.). I hereby waive any right to inspect or approve the use of images or recordings. I further waive all moral rights. I also waive any right to royalties or other compensation arising from or related to the use of the images, recordings, or materials.

I hereby release, waive, forever discharge, and covenant not to sue the FLTA Charitable Action Foundation, its governing board, officers, agents, employees, and any members acting on behalf of the FLTA Charitable Action Foundation from and against any claims, damages, or liability arising from or related to the use of the images, recordings, or materials, including but not limited to claims for defamation, invasion of privacy right of publicity or copyright infringement, or any misuse, distortion, blurring, alternation, optical illusion, or use of composite form that may occur or be produced in taking, processing, reduction, or production of the finished product, its publication or distribution.

I acknowledge that this consent, waiver, indemnity, release, and covenant not to sue is binding on me, my heirs, executors, administrators, and assigns. By submitting this application, I acknowledge that I read this document, and I fully understand the contents, meaning, and impact of this consent, waiver, indemnity, release, and covenant not to sue.

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