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United Way of Weld County Community Impact Partner* Application
*the term “Partner” does not and will not imply a legal connection between United Way of Weld County and the applicant organization
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* Indicates required question
Legal Name of Organization
*
Your answer
DBA (if applicable)
Your answer
Mailing Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
Physical address if it is different and not confidential
Your answer
Phone
*
Your answer
Fax
Your answer
Employer Identification Number (EIN)
*
Your answer
Website
*
Your answer
Organization Email Address
*
Your answer
Name of CEO or Executive Director
*
Your answer
Phone
*
Your answer
Email
*
Your answer
Other Contact Person & Title (if other than the CEO or executive director)
Your answer
Phone
Your answer
Email
Your answer
Organization Information
Year Founded
*
Your answer
Mission Statement
*
Your answer
Tax Exempt Status
*
501(c)(3)
Using a fiscal agent/fiscal sponsor - please name
Other than a 501(c)(3) - please describe
Required
If you chose "using a fiscal agent/fiscal sponsor" or "other," please describe.
Your answer
Provide a 50-75 word description of the agency and its programs.
*
Your answer
Which agency program will be populated to the Thriving Weld Dashboard and reported on at least quarterly? After becoming a Community Impact Partner, agencies may populate multiple programs to the Thriving Weld Dashboard.
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Please send a completed logic model for this program to
serita@unitedway-weld.org
. To download the logic model template, click here:
https://goo.gl/thuLXD
Your answer
Better Business Bureau Charity Accreditation is mandatory for Community Impact Partners. Does the agency currently have Better Business Bureau Charity Accreditation?
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Yes
No
If No, what month/year will the agency begin the accreditation process?
Your answer
This application information is true and correct to the best of my knowledge.
*
Please enter the first and last names of the agency CEO/Executive Director or Board of Directors Chair below to sign your agreement.
Your answer
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