Psi Iota Xi, Zeta Chapter, is a philanthropic sorority which earns money from the operation of The Bloomington Thrift Shop, Inc. Each year we share these funds with Community organizations in the fields of music, art, education and service.

Application for Contribution
to be submitted to The Philanthropic Committee

Date Submitted __________ Date Received __________

Psi Iota Xi Member Submitting Request __________________________________________________

Amount Requested ________________________ Months Funds Requested _____________________

Name of Organization: _______________________________________________________________

Address ______________________________________________________________________

Telephone Number _____________________________________________________________

Contact Person for Organization _______________________________________________________

Address ______________________________________________________________________

Telephone Number _____________________________________________________________

Type of Organization--Check one: Private Non-Profit______ Individual______ Public Agency______

How old is the organization? ___________________________________________________________

Describe the organization: _____________________________________________________________

___________________________________________________________________________________

____________________________________________________________________________________

___________________________________________________________________________________

Specify how the money is to be spent: ____________________________________________________

___________________________________________________________________________________

Who will be served by this contribution: List information such as number of persons, age group, or any information which will help us to understand the importance of this request.

_____________________________________________________________________________________

List the major sources of funding for the organization:

_____________________________________________________________________________________

If there is any other information you feel is pertinent to this request, please use this space.

_____________________________________________________________________________________

If this request is funded, you will receive notification by May 1^st.

Please send this application form to:                  Donna Gentille                          Jeanne Madison
                                                                        4100 Morningside Dr.              2901 Olcott Blvd.
                                                                       Bloomington, IN 47408            Bloomington, IN 47401

Application for Contribution to be submitted to The Philanthropic Committee

Application for Contribution
to be submitted to The Philanthropic Committee