ESCC Request for Assistance

Thank you for your interest in working with ESCC. Please complete this request form in its entirety. Once we receive the request, we can begin working with you. Upon completion, you should receive a message letting you know the form has been submitted successfully. If you do not receive a confirmation, please contact the Operations Manager at 513.791.6230.

The request form can also be downloaded as a Word or .pdf document and emailed or faxed to the ESCC office.

Request Assistance in word

Request Assistance as .pdf

If you have questions, please contact the Operations Manager at 513.791.6230.

*Required

Legal Organization Name:
Address:
City:
State:
Zip Code:
Phone:
Email:
Purpose of Organization and Clients Served:
Year Founded:
Is this organization a certified non-profit?: Yes No

Executive Director:
Board President/Chair:
Person with whom ESCC will be working:
Title of person listed above:
Is the person listed above aware of the request?: Yes No

Is the Executive Director aware of this request?: Yes No

Is the Board President aware of this request?: Yes No

Income last year end or fiscal reporting year end:
Total Expenses last year end or fiscal reporting year end:
Number of paid full-time employees:
Description of the assistance needed (please be specific and include information to help us understand your situation):
How did you hear of ESCC?:
Additional Comments:
Name and Title of person submitting this request: