Hermanowski Family Foundation Initial Request Form

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Organization Name: Q and K Alopecia Foundation
Legal Name (if Different):
Also Known As: Queens & Kings of Alopecia
Mailing Address: 301 Lamplighter Lane
City: Birmingham
State: AL
Postal Code: 35214
Main Phone: (205) 918-3388
Main Fax: (205)518-6686
Organization Website: Facebook: Queens & King s of Alopecia Support Group
Employer ID Number:
Organization Tax Status:

Proposal Information

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Today’s Date:
Requested Amount:

Project Title:
Project Description:

Total Project Budget:

Other Funding
Sources For The Project (Committed & Potential):

Project Duration:
Geographical Area Served:
Age Group To Be Served:

Contact Information

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Contact Prefix (Mr,Mrs etc.):
Contact First Name:
Contact Last Name:
Contact Title:
Contact Phone:
Contact Email: