Servicing Southwest Ohio, Northern Kentucky, and Southeast IndianaFriday November 21, 2008

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CONFIDENTIAL (download PDF or WORD for mailing) (get PDF Reader)
Date:
Organization Name:
Address:
Phone:
Fax:
Email:
Purpose of organization and clients served
Year Founded:
Is organization certified nonprofit:
Director:
Board President:
Person with whom ESCC will be working:
Title of person listed above:
Is the person listed above aware of this request:
Is the Executive Director aware of this request:
Is the Board President aware of this request:
Is the Board aware of this request:
BUDGET
Budget for Current Year Actual from Previous Year
Revenue Sources
  Contribution
  Foundation Grants
  Government Income
  Special Events
  Program Income
  Other
Expenses
  Administrative Costs
  Fundraising Fees
  Program Costs
Number of Paid Employees Full Time Part Time
  Professionals
   inc. management
  Office Staff/clerical support
  Other
Number of Volunteers
Describe the assistance needed. Be specific and include information to help us understand your situation.
Describe the areas of experience in ESCC consultants
Estimate time required by consultants:
Indicate the date assistance is needed and any significant time constraints
Describe any issues or problems that may affect ESCC's efforts
What end result do you expect
How did you hear of ESCC
Additional Comments
Notes/Privacy Disclosure
In addition to that information given willfully on this form the following additional information is also collected from your web browser and submitted as supporting information when possible: Computer IP Address, Computer Hostname, ISP, Browser Type, Browser Version. ESCC keeps this and all information in the strictest confidence.
DO YOU AGREE TO THE FOLLOWING
I agree with the above statement.

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