:: United Way of Central Jersey ::

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Applicant Agency Profile

SECTION 1

Program Name:
Organization Name:
Name of Executive Director/President/CEO:
Organization Address (Main Office):
Organization Mailing Address (if different from above):
Phone:
Fax:
Website:

SECTION 2

Organization’s Mission Statement:

Accessibility

Are the organization’s facilities accessible to people with disabilities?

Yes

Are services accessible to people with disabilities?

Yes

Is the organization accessible by public transportation?

Yes

SECTION 3

Please check each eligibility requirement below to indicate the organization’s commitment and ability to fulfill the requirement. All information is required; however, please DO NOT include the supporting documentation with the Letter of Intent packet. If a Full Proposal is requested, the supporting documentation will be necessary at that time.

Has clear mission statement for the organization.

	Has clear mission statement for the organization.
	As a Not-For-Profit applicant, has Articles of Incorporation and exemption from Federal income tax under Section 501c(3) or is exempt from taxation under another section of the IRS Code.
	Has current Board of Directors list with terms of offices and minutes of the last six Board meetings.
	Has most recent annual certified audit or financial statements and annual report.
	Has IRS Form 990 or 990EZ.
	Has updated Strategic Plan
	Has stated policies of nondiscrimination and complies with all the requirements of state and Federal laws and regulations on nondiscrimination and equal opportunity with respect to clients, officers, employees, and volunteers.
	Does not knowingly employ individuals or contribute funds to organizations found on terrorist-related lists officially announced by the U.S. Government, the United Nations or the European Union.
	Can submit certification to United Way indicating compliance with the spirit and intent of the U.S.A. Patriot Act and other counterterrorism laws as requested.
	Has a demonstrated expertise with the initiative or program covered in the Proposal.
	Has ability to identify and to measure outcomes and to report results and cooperate in an outcome measurement process.
	Has current copies of Licensure or Accreditation (if applicable).
	Agrees to comply with United Way’s Agency Agreement requirements, including conducting an annual United Way campaign with the Board, agency volunteers and staff.

I attest that I am in agreement with the stated program structure and my agency’s role in it. I further affirm that I have reviewed the Letter of Intent packet and, to the best of my knowledge, the information furnished is correct and provides full and fair disclosure.


Signature, Executive Director/President/CEO		Signature, Board President/Chair/Designee

Print Name of Executive Director/President/CEO		Print Name of Board President/Chair/Designee

Date		Date