Address* [Street Address] Local Headquarters Street Address with Suite #, if [City], [State] [Zip] needed Satellite offices* National Affiliate Name, if your agency is a How many satellite office and/or program sites affiliate (50 characters) does your agency have, if any? [National Affiliate Name - limit 50 characters] Web Address* [Website] Main Phone including area code* Executive Director/CEO Name* [ED/CEO Name] Local Executive Director/CEO Title* [ED/CEO Title] [ED/CEO Direct Phone] Local Executive Director/CEO Direct Phone* Executive Director/CEO Email* [ED/CEO POINT OF CONTACT FOR THIS APPLICATION Primary of Contact Name* [Contact Name] Primary Point of Contact Title* [Contact Primary Point of Contact Direct Phone* [Contact Phone] Primary Point of Contact Email* [Contact Email] STAFFING AND BOARD Number of Full Time Equivalent Employees* [FTE] Number of Governing Board Members* Members] Exclude Advisory/Emeritus members Number of Total Volunteers* [Volunteers] Exclude Board members Executive Director Tenure [ED/CEO Tenure] How many years (or months, if under one year) has your local Executive Director/CEO been in his/her role? (e.g. 9 yrs or 8 mos.)
Address* Local Headquarters Street Address with Suite #, if needed [Street Address] [City], [State] [Zip] Satellite offices* How many satellite office and/or program sites does your agency have, if any? National Affiliate Name, if your agency is a affiliate (50 characters) [National Affiliate Name - limit 50 characters] Web Address* [Website] Main Phone including area code* Executive Director/CEO Name* [ED/CEO Name] Local Executive Director/CEO Title* [ED/CEO Title] Local Executive Director/CEO Direct Phone* [ED/CEO Direct Phone] Executive Director/CEO Email* [ED/CEO POINT OF CONTACT FOR THIS APPLICATION Primary of Contact Name* [Contact Name] Primary Point of Contact Title* [Contact Primary Point of Contact Direct Phone* [Contact Phone] Primary Point of Contact Email* [Contact Email] STAFFING AND BOARD Number of Full Time Equivalent Employees* [FTE] Number of Governing Board Members* Exclude Advisory/Emeritus members Members] Number of Total Volunteers* Exclude Board members [Volunteers] Executive Director Tenure How many years (or months, if under one year) has your local Executive Director/CEO been in his/her role? (e.g. 9 yrs or 8 mos.) [ED/CEO Tenure]
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