New Partner Interest Form

New Partner Interest Form

Thank you for your interest in being a Partner Agency with CRC. Please complete the following form so that we may best determine your organization's eligibility. After reviewing your submission, we will follow up with our decision regarding if we would like to move forward with your organization in our application process.
1. Agency Name
2. Agency Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
3. Our agency is (please select any/all that apply):

Other
4. What counties does your agency serve? Please check all counties where your agency provides services.

Other
5. Do you ask clients for donations, charge a fee, or require attendance at a service or gathering to receive services?

Other
Please note, if you have answered 'Yes' to the question above, you do not meet our minimum eligibility requirements to become a CRC Partner Agency.
6. Tell us about your agency and your interest in partnering with the Community Resource Center.
Please provide a brief description of your organization's program(s) to help us better understand how you serve your community and how you intend to use hygiene products obtained from the CRC.
7. Does your agency provide products and/or services at more than one location/site?
7a. Please list all locations where your agency provides products and services.
Please include site name and full address for each location.
8. Select the type(s) of service(s) your agency provides. Please check all that apply.

Other
For the question below, please refer to these Agency type definitions:
- An "Open" agency is an agency where the general public has access to your resources/services.
- A "Program Only" agency is an agency whose resources/services are provided exclusively to clients that are engaged in the agency’s programming and do not offer resources/services to the general public.
9. What is your Agency type?
10. Does your agency currently provide personal hygiene or cleaning products to your clients/service population?
11. What is the total number of unique individuals your agency typically serves annually?
If your agency does not track this data, please provide your best educated estimate.
12. What is the average number of individuals your agency typically serves in a month?
If your agency does not track this data, please provide your best educated estimate.
Agency's Main Contact - Name
First and Last Name
Agency's Main Contact - Role
What is your title/role within the agency?
Agency's Main Contact - Email
example@example.com
Agency's Main Contact - Phone Number
Signature of Authorized Representative from Your Agency
Should be Empty: