ORGANIZATION APPLICATION

Organization Name:

Address

City:

State:

Zip:

Contact Name:

Phone:

Email Address:

Website Address:

Requested Walk Location:

1. Is your organization a 501(c)3 non-profit?

Yes No

2. When was the nonprofit founded (i.e. YYYY)?

3. What is your mission?

4. What specific services does your organization provide? To what population?

5a. Our organization is:

Local (area in one county) Regional (multi-county) National (local chapter)

5b. Number (approximate) of people served yearly

5c. Number of full-time employees:

5d. Number of part-time employees:

5e. Number of active volunteers

6. Do any of your employees have fundraising experience?

Yes No

If yes, please list names and titles:

7a. Do you have a board of directors?

Yes No

7b. Are any of your board members Highmark Inc. employees?

Yes No

If yes, please list names:

8. Please list your current fundraising events and dates for these events.

9. Have you received grants or sponsorship dollars from Highmark Inc. in the last year?

Yes No

10. Does your organization carry Highmark Inc. insurance?

Yes No

11. Is anyone in your organization related to a Highmark Inc. employee?

Yes No

If yes, please list Highmark Inc. employee and relation to organization employee:

12. Do you have a staff person who can be the main contact and attend all meetings?

Yes No