Tell Us More About You

Please take a moment to fill out the form and we will be back in touch with you.

* Required fields

General Information
Non-Profit Name: *
Contact Name: *
Location Address: *
City: *
State:	Zip:
Business Phone: *	Ext.:
Contact E-mail: *
Website:

Application Questions

Are you a 501(c) 3 under the U.S. Internal Revenue Code?

Yes No

Do you conduct any special fundraising events?

Yes No

Event & Fundraisers:

Date	Event	No. of Participants	Revenue
			$
			$
			$
			$

Total number of employees?

Total number of volunteers?

Annual Budget:

Annual Payroll:

From the list below specify your major source of funding by indicating the proportion of income from each source – for example Private Donations 30% Fundraising 40% Grants 10% Other 20%

Services:

Fundraising:

Private Donations:

Grants:

Other:

Do you provide lodging?

Yes No

Are you required to be licensed?

Yes No

10.

Do you have a Certified Drug Free Workplace?

Yes No

11.

Do you provide any medical services?

Yes No

If YES, please provide details:

12.

When was the last complete assessment of your insurance program performed? (Month/Year)

13.

Are all your insurance needs met by one insurance provider?

Yes No

If YES, please provide details:

This information will be kept confidential and will be used for proposal purposes only.