EFSP Applicant Screening Tool

EFSP Applicant Screening Tool
Date

MonthDayYear
Date
Name*

First NameLast Name
Primary Contact Name*

First NameLast Name
Primary Contact Title*
Email*
example@example.com
Contact Number*

Area CodePhone Number
Tax Exempt EIN*
Agency Name*
Program Name*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Website
AGENCY Information
1. Non-profit 501 (c) 3 organization?*

YesNo
2. Are individuals, families or households charged a fee for service or required to attend religious/counseling services to receive assistance?*

YesNo
3. Which emergency service(s) do you currently provide? (select all that apply)

Shelter AssistanceFood AssistanceRent/Mortgage/Utility Assistance
4. Will requested funds be used to expand current services?*

YesNo
5. Does your organization have the ability to work on a reimbursement basis?*

YesNo
6. Please select the county in which services are provided.*

Crittenden CountyShelby County
7. Are services available to any qualified individual in Shelby and/or Crittenden County ?*

YesNo
Should be Empty:

AGENCY Information