Organization:

_____________________

Contact First Name:

_____________________

Contact Last Name:

_____________________

Title:

_____________________

Phone:

 

( ___)

__________

ext. ______

Fax:

 

( ___)

__________

ext. ______

Email:

_____________________

Website:

_____________________

Approximate # of clients served:

_____________________

Address

_____________________

City

_____________________

State

_____________________

Zip or postal code

_____________________

Purpose or mission of your organization:

_____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________

Executive Director:

_____________________

Board Chair/President

_____________________

Number of board members:

_____________________

Standing CommitteesNumber of Members

_____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________

Number of paid employees:

_____________________

Number of volunteers:

_____________________

Budget for fiscal year ending ______ is $ _____________________.

Please tell us the functional areas in which you would like assistance, and describe in as much detail as possible the specific results you would like ESC consultants to help you accomplish:

_____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________

Referred by:

_____________________