Partner Intake Form - Imagine with a Mission

Community Partner - General Information

Legal Business Name*

Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Business Email Address*

example@example.com

Business Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

State of Incorporation *

Federal ID/EIN #

Community Partner - Main Point of Contact

Full Name*

First NameLast Name

Title

Cell Phone*

Please enter a valid phone number.Format: (000) 000-0000.

Email Address*

example@example.com

Personal Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

List all owners - please note that a resume/curriculum vitae (CV) must also be attached for each owner.

Owner 1 Full Name*

First NameLast Name

Owner 2 Full Name

First NameLast Name

Owner 3 Full Name

First NameLast Name

Owner 4 Full Name

First NameLast Name

Community Partner - Employees

List all key employees and provide a brief job description of each

Employee 1 - Full Name

First NameLast Name

Employee 1 - Job Description

Employee 2 - Full Name

First NameLast Name

Employee 2 - Job Description

Employee 3 - Full Name

First NameLast Name

Employee 3 - Job Description

Employee 4 - Full Name

First NameLast Name

Employee 4 - Job Description

Community Partner And/or Owner Current or Pending Litigation

YesNo

If yes, please provide a description of the current of pending litigation:

YesNo

If yes, please provide a description of the current of pending litigation:

Community Partner - Insurance

List the name of the insurance agency that the requesting entity is insured with - please note that an insurance declarations page showing all types and amounts of insurance coverage must be submitted.

Name of Insurance Agency

Community Partner - a Potential Partnership with Imagine with a Mission

Identify the IWAM project for which the Community Partner seeks funding: *

Identify the duration of the project: *

Name the skills and expertise (e.g. construction, counseling, tutoring) of the Community Partner:*

Provide information of any relevant experience with similar projects:*

Provide three relevant references for projects completed by the Community Partner:

Reference 1 - Full Name

First NameLast Name

Reference 1 - Organization/Business and Title

Reference 1 - Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Reference 1 - Email

example@example.com

Reference 2 - Full Name

First NameLast Name

Reference 2 - Organization/Business and Title

Reference 2 - Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Reference 2 - Email

example@example.com

Reference 3 – Full Name

First NameLast Name

Reference 3 - Organization/Business and Title

Reference 3 - Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Reference 3 - Email

example@example.com

COMMUNITY PARTNER – BUDGET REQUESTED

Identify the total amount of requested funding: *

Identify the total amount of funding needed in the first 90 days of the project: *

Provide a budget breakdown – specify how the requested funding will be used: *

Provide estimated timelines for any project milestones:*

Community Partner – Justification

Describe why the Community Partner’s mission aligns with the goal of the IWAM project:*

Community Partner - Checklist of Documents Needed for Submission

Please submit only PDFs

Resume/CV of Owner 1

Resumer/CV of Owner 2

Financial Statement for Most Recent Fiscal YEar

Insurance declarations page showing all types and amounts of insurance coverage

Any other supporting documentation regarding budget, timeline or partner mission alignment with IWAM

Resume/CV of all ownersFinancial statements for the most recent fiscal yearInsurance declarations page showing all types and amounts of insurance coverageAny other supporting documentation regarding budget, timeline, or partner mission alignment with IWAM

Signature