Mindful Philanthropy Intake Form

Mindful Philanthropy

Organization Intake Form
Name*

First NameLast Name
Email*
Role at Organization*
Organization Name*
Organization Type*

501c3501c4B corpLLCOther
Organization Website*
Year Founded*
Is your organization an affiliate of another organization? If so, please provide the name:
What are your organization’s mission and vision statements?*
What is your organization’s geographic focus area?*
Please select all the US states that correspond with your geographic focus.*

We operate nationwide.AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington D.C.West VirginiaWisconsinWyoming
What are the key activities, programs, or components of the organization to solve the social issue area(s) at hand? *
How do these activities relate to mental health, addiction, or community well-being? *
Which populations and communities does your organization serve?*
What is your current annual operating budget?*
Please attach your organization’s latest 990 form:*

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How did you hear about Mindful Philanthropy?*
Certification

By submitting this form, I confirm that:
- I have the authority to submit this form.
- All information contained herein is true and accurate to the best of my knowledge.
- Mindful Philanthropy has permission to contact me at the email and phone number provided.
- I am aware that this is not a funding proposal, and that submitting this form does not guarantee funding.
Should be Empty: