To:                                                                From:
    Pratt-Northam Foundation                                   _____________________________________
    Attn: Thomas Yousey                                                 (Name of Applicant)

    PO Box 104                                                 _____________________________________
                                                                          (Street Address)

    Lowville, NY 13367                                         _____________________________________
                                                                      (City, State, Zip Code)
____________________________________________________________________________________________________
Part I. Information about the Applicant
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1. Is the applicant organized as a nonprofit organization under State
   laws governing charitable organzitions?                     ( )Yes ( )No
   If yes, what State or Commonwealth governs?
   If no, please explain:

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2. Has the applicant received a ruling or determination letter from the 
   Internal Revenue Service about any of the following?
   a. Exempt status                                            ( )Yes ( )No
   b. Private foundation status                                ( )Yes ( )No
   c. Grant-making procedures                                  ( )Yes ( )No
   d. Municipal body, Town, Village, County, etc.              ( )Yes ( )No
   Attach a photocopy of each such letter. a. copy of letter attached.
   If any item is marked no, explain: b. and c.  We are a civic association
   exempt under section 501c 4 of the Internal Revenue Code and thus are
   not subject to the private foundation rules.

3. a. Attach a copy of the applicant's proposed project for the year in which
      the grant funds are to be used.
   b. If this grant will be a substantial and material part of the budget, 
      attach a copy of the latest information return (Form990 or 990PF) filed
      by the applicant with the Internal Revenue Service.
   c. Describe the applicant's purposes and activities in general.
      Please respond to these questions on a separate sheet.
____________________________________________________________________________________________________
4. Is the applicant controlled by, related to, connected with, or sponsored
   by another organization?                                    ( )Yes ( )No
   If yes, identify the organization including its purpose and
   activities and explain the relationship:

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5. List the name and address and title of each member of the applicant's 
   governing board.  If municipal, list chief elected official and fiscal 
   officer.

____________________________________________             ___________________________________________
                  (Name)                                              (Title or office)

____________________________________________             ___________________________________________
             (Street Address)                                         (City, State, ZIP)

____________________________________________             ___________________________________________
                  (Name)                                              (Title or office)

____________________________________________             ___________________________________________
             (Street Address)                                         (City, State, ZIP)

____________________________________________             ___________________________________________
                  (Name)                                              (Title or office)

____________________________________________             ___________________________________________
             (Street Address)                                         (City, State, ZIP)
6. Has the applicant (or any organization listed in 4, above) ever applied
   for or received a grant from this foundation?               ( )Yes ( )No
   If yes, give details:

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Part II. Use of the proposed grant
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7. Show the amount requested and explain in detail how it will be used. 
   State whether the grant is to be earmarked for the use of benefit of any 
   one person, group, or class of people.  If so, for whom?

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8. Person to contact who will be administering the proposed program.

____________________________________________             ___________________________________________
                   (Name)                                                  (Title)

____________________________________________             ___________________________________________
              (Street Address)                                       (City, State, ZIP)

____________________________________________
       (Area code and Telephone #)

    From my own knowledge, I state that the information given in Parts I and
II is correct.  The applicant organization has authorized me to make this 
application.

                                              ______________________________________  ______________
                                                             (Name)                       (Date)

                                              ______________________________________
                                                       (Title or Office)
____________________________________________________________________________________________________
   The information in Parts I and II is help the grantor foundation meet the 
requirements of section 4945 h of the Internal Revenue Code.
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Part III. To be filled in by Pratt-Northam
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9.  Evaluation by grant or program committee:

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10. Special supervisory or follow-up requirements, if any:

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11. Remarks:


____________________________________________________________________________________________________

    __________________                               _______________________________________________
         (Date)                                           (Grant or program committee, Chrm.)
____________________________________________________________________________________________________
12. Action taken. (Person to approve action must initial and date)
    a. Approved as requested                (__________________________________________)
    b. Approved as modified, see Remarks    (__________________________________________)
    c. Denied                               (__________________________________________)
    d. Date of grant agreement              (__________________________________________)
    e. Amount of grant $_______________     (__________________________________________)
    f. Date of grant ____________           (__________________________________________)
    g. Date of interim report ____________  (__________________________________________)
    h. Date of final report _____________   (__________________________________________)
    i. Date of file closed _____________    (__________________________________________)
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