Request for In-State Travel Reimbursement

N.C. Counts Coalition will provide a limited number of travel stipends to  North Carolina established nonprofit and grassroot organizations in the following counties: Mecklenburg, Anson, Bertie, Cumberland, Duplin, Edgecombe, Halifax, Hoke, Northampton, Robeson, Sampson, Scotland, Vance, Lenoir, Guilford and Swain. 

First Name*

Last Name*

Title*

Organization Name*

Organization's Mission *

What is your organization's mission?

Email Address*

Phone Number*

Address 1*

Address 2

City*

State* AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip*

Distance to Event Location *

Using google maps, what is the total mileage, one way, from the address of your organization to the event?

What is 2+2?*

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