Wealth Screening Request Form

Central Connecticut State University

Advancement Services Wealth Screening Request Form
REQUESTOR INFORMATION
Name *

First Name Last Name
Email *
datarequest@ccsu.edu
CCSU extension *
ex. 21747
REQUEST INFORMATION
Purpose *

Wealth Screening
Date required (allow 5 working days lead time if possible) *

Month Day Year
Number of constituents to be screened (max. 12) *
CONSTITUENT INFORMATION
Constituent Raiser's Edge ID 1 *
Constituent First Name 1 *
Constituent Last Name 1 *
Constituent Raiser's Edge ID 2 *
Constituent First Name 2 *
Constituent Last Name 2 *
Constituent Raiser's Edge ID 3 *
Constituent First Name 3 *
Constituent Last Name 3 *
Constituent Raiser's Edge ID 4 *
Constituent First Name 4 *
Constituent Last Name 4 *
Constituent Raiser's Edge ID 5 *
Constituent First Name 5 *
Constituent Last Name 5 *
Constituent Raiser's Edge ID 6 *
Constituent First Name 6 *
Constituent Last Name 6 *
Constituent Raiser's Edge ID 7 *
Constituent First Name 7 *
Constituent Last Name 7 *
Constituent Raiser's Edge ID 8 *
Constituent First Name 8 *
Constituent Last Name 8 *
Constituent Raiser's Edge ID 9 *
Constituent First Name 9 *
Constituent Last Name 9 *
Constituent Raiser's Edge ID 10 *
Constituent First Name 10 *
Constituent Last Name 10 *
Constituent Raiser's Edge ID 11 *
Constituent First Name 11 *
Constituent Last Name 11 *
Constituent Raiser's Edge ID 12 *
Constituent First Name 12 *
Constituent Last Name 12 *
Demographic information to include *

Raiser’s Edge ID Date of Birth (if available) Class Year (If applicable) Degree & Major Spouse ID (if applicable) Spouse Name (if applicable) Spouse Class Year (if applicable) Home Phone (if available) Home Cell Phone (if available) Home Email (if available) Facebook Link (if available) LinkedIn Link (if available) Website (if available)
Wealth Ratings to include *

Total Assets Cash on Hand Estimated Annual Donations Gift Capacity Range Income Real Estate Total Value Total Property Count
Other Information to Include *

Additional Philanthropic (non-CCSU) Giving Federal Election Contributions State Election Contributions Associations Businesses Spouse Businesses (if applicable) Real Estate
Include CCSU cumulative giving? *

Yes No
The Development Officer(s) Assigned to my Area is/are: *

Laura Marchese (Business / Engineering, Science & Technology) Mary Beth Papallo (Education & Professional Studies) There is no development officer assigned to my area.
I have a file to upload *

Yes No
Files(s) to upload *

Browse Files

Cancel of
I have additional instructions to enter *

Yes No
Additional instructions *
TERMS & CONDITIONS
I, {REQUESTERNAME}:

understand that I must treat this data provided by CCSU Advancement Services as confidential and use it only for University-related initiatives.

will exercise care when handling and transmitting any data provided by CCSU Advancement Services. Every effort should be made to collect and share only necessary information and to maintain and share such data in a reasonably secure form.

understand the data provided by CCSU Advancement Services is to be used for informational purposes only. The Advancement Services database is the most comprehensive database on campus for alumni and donor information and is updated on a daily basis. The information provided must not be used to create separate constituent databases and should not be retained once the specified use has been completed.

will forward in full corrections and additions to the information provided by CCSU Advancement Services to gordonjo@ccsu.edu, or by campus mail to the Advancement Services Office - Clarence Carroll Hall - Room 343.

will only use wealth information for 30 days after information has been received and request updated information for any subsequent initiatives.

will contact Joe Gordon, Director, Advancement Services – 860-832-1747 or gordonjo@ccsu.edu with any questions regarding appropriate use, sharing, and protection of data provided by CCSU Advancement Services.
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Central Connecticut State University