VeriFyi Membership Application
In addition to this application, please upload the following documents
Copy of 501(c)(3) letter; or if tax-supported entity, submit documentation verifying Agency's tax-exempt status
List of Agency's Board of Directors, Advisory Board, or highest governing body
Current agency brochure, newsletter or copy of your website homepage
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All information must be completed to process your application.
Date
-
Month
-
Day
Year
Date
Agency Name (as listed on 501(c)(3))
Agency's Date of Incorporation
Mailing Name (if different than agency name)
Agency's Main Phone Number
Format: (000) 000-0000.
Agency's Physical Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Same as Mailing Address
Agency's Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
Closest Major Intersection
Website Address
Agency Mission Statement
Agency's Operating Hours:
Operating Hours
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Additional Locations (with addresses and zip codes)
Agency Type
501(c)(3)
Tax-Supported Entity
United Way Agency
For-Profit Organization
Faith-Based Organization
Sports Organization
Executive Director
Phone Number
Format: (000) 000-0000.
E- Mail Address
example@example.com
Background Check Contact
Phone Number
Format: (000) 000-0000.
E- Mail Address
example@example.com
Secondary Background Check Contact (if applicable)
Phone Number
Format: (000) 000-0000.
E- Mail Address
example@example.com
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Agency
Name
CAUSES / CLIENT POPULATION/ETHNIC BREAKDOWN
CAUSES SERVED: (Check NO MORE THAN FOUR Categories)
CAUSES SERVED: (Check NO MORE THAN FOUR Categories)
Abuse/Domestic Violence
Education
Legal Issues
Literacy
Employment/Job Training
Literacy
Adoption
Environment
Mentoring
Mentoring
Ethnic/Cultural Issues
Nonprofit Administration
AIDS/HIV
Food Assistance
Recreation/Sports
Nonprofit Administration
Health
Senior Services
Animal Care/Advocacy
Homelessness
Substances Abuse Prevention
Recreation/Sports
Hospice/Home Support
Teen Pregnancy/Parenting
Senior Services
Substance Abuse Prevention
Teen/Community Pregnancy/Parenting Development
Hospital Services
Violence Prevention
Violence/Counseling/Crisis Prevention
Disabilities/Mental & Physical
Immigration/Refugee Assistance
POPULATION SERVED: (Check NO MORE THAN THREE Categories)
POPULATION SERVED: (Check NO MORE THAN THREE Categories)
Adult Men
Children/Elementary
General Public
Teenagers
Adult Women
Children/Preschool
Infants
Other
Animals
Families
Senior Citizens
ETHNIC MAKEUP OF CLIENTS: (Use PERCENTAGES to total 100 percent; use whole numbers only)
ETHNIC MAKEUP OF CLIENTS: (Use PERCENTAGES to total 100 percent; use whole numbers only)
African American
Anglo
Asian/Pacific Islander
Hispanic
Native American
Other
VeriFyi Membership Agreement
I (Agency Representative),
of (indicate agency)
as a representative upon meeting the criteria established for the VeriFyi program, agree to sign and follow the VeriFyi Service Agreement (VSA). The VSA is required for participation in the criminal background check program. By signing this document, I acknowledge that the agency will pay a fee for each background check performed, including alias searches. I understand that if I opt to run alias searches automatically, I may change this option by submitting a written letter to VolunterNow indicating my new choice.
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Date
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