for office use only

• This form is best viewed in Internet Explorer or Netscape browsers, version 5 or higher.
• Please read and print instructions before completing this form.
• After completing this page, print it and go to the next section.
• Some printers may not print checkboxes and radio buttons. You may complete those in ink.
• Your cannot save the completed form to your computer.

A. Applicant Section

Organization Name:

Federal Employer's ID (Last 4 digits only):

Contact Person:

Contact Person's Title:



State: Zip code:

E-mail Address:

Web site Address:

Telephone (daytime):


Legislative District Numbers (If you don't know your district numbers, click here.)
Iowa House #:  Iowa Senate #:  US Congress #:

Type of Applicant: (select one)
Non-profit Organization
Indian Tribe

Applicant Profile: Describe your organization's purpose, mission, primary discipline areas and primary service area. Limit response to ~150 words (~1100 characters) or your printer may not print all text.

Project Information

Project Title:

Project Summary: Describe your project in 2-3 sentences to be used in press releases (~50 words or 500 characters)

Proposed Project Dates (month/day/year):
From to

Was this project in existence prior to the program deadline?
Yes    No

Has this project received funding from the State Historical Society of Iowa, the Iowa Arts Council, or the Iowa Department of Cultural Affairs in the current or previous year?  
Yes    No

If yes, from which grant program(s) did the project receive funding and how much was the grant amount?

Iowa Arts Council Grants:
Historical Society Grants:
Iowa Department of Cultural Affairs Grants:

The site in question is: (select one)

Listed on the National Register of Historic Places
Declared eligible by the State Historic Preservation Office for listing on the National Register of Historic Places
A facility in which Iowa's history or the heritage of Iowa's people is interpreted

Is there any Federal involvement in your project?
(Federal involvement could include funding, licensing, permitting or other types of assistance.)
If yes, list the name of the Federal agency:

Go to next section>>