Statement of Interest

Statement of Interest Form
Thank you for your interest in United Way of the Mid-South. Please complete the information below. If you have questions, please contact Janet Haas at janet.haas@uwmidsouth.org
Today's Date

MonthDayYear
DateHourMinutesAM/PM Option
AGENCY INFORMATION
Name of Agency*
Physical Address*

Street Address

CityState

Zip Code
Mailing Address (if different from physical address)

Street Address

CityState

Zip Code
Executive Director*

First NameLast Name
E-mail*
Phone Number

Area CodePhone Number
Website?
Which county(ies) do you serve?*

CrittendenDeSotoFayetteLauderdaleMarshallShelbyTateTiptonTunica
Are you tax exempt under section 501(c)3 of the Internal Revenue Service Code?*

YesNo
Please indicate the Area(s) of Service your agency provides:

Adult Disability ServicesAdult Education and TrainingAlcohol and DrugChildren 0-5Crisis Intervention/HotlineDisabilities 0-5Domestic ViolenceEmergency Assistance - Material, Food, Rent/Mortgage, UtilitiesEmergency Housing/HomelessnessFinancial Literacy/Housing EducationFoster CareHealth and Wellness EducationHIV/AIDS Services/EducationHomelessness/Housing/Community DevelopmentImmigrant ServicesInformation and ReferralJob Readiness/TrainingLiteracyMental Health - AdultMental Health - YouthMentoringPhysical HealthSenior ServicesVolunteerYouth Education/TrainingYouth RecreationOther
Please describe the target population receiving your service(s) and the issue or opportunity your service addresses.*
Should be Empty:

Statement of Interest Form