C3 Workshop Required Questionnaire 1. Default Section Question Title 1. Please provide the following information about you and the organization you represent. Organization: Contact Name and Job Title: Address: Address 2: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code: County: Email Address: Phone Number: Question Title 2. Please provide the following information about your organization. Website: Fax Number: Question Title 3. Please provide the names of individuals registering for the workshop on Feb. 4, 2010. 1. 2. 3. 4. 5. Question Title 4. Please state your organization's purpose or mission. Question Title 5. When was your organization established? Question Title 6. Select areas served by your organization (check all that apply). Lexington County Richland County Other (please specify) Question Title 7. What type of services are provided by your organization? (Check all that apply.) Social Services Arts/Culture Education Healthcare Other (please specify) Question Title 8. What is your organization's current fiscal year's budget? $25,000-$100,000 $100,001-$250,000 $250,001-$500,000 $500,000-$1,000,000 $1,000,001-$2,000,000 More than $2,000,000 Question Title 9. Is your organization affiliated with a national organization? Yes No If yes, please name national organization Question Title 10. Current funding sources for your organization are: (Check all that apply.) Foundations State Fundraising events Local government Federal government Corporations Individual donations Fees for service Question Title 11. Is your organization currently in discussions with one or more other organizations for new collaborations? Yes No Question Title 12. What type of assistance are you looking for? Exploring a formal partnership with another organization Assuming administrative functions with another organization (payroll, reception) Transferring administrative functions to another organization (payroll, reception) Co-locating or sharing office space with another organization Exploring a merger with another organization Assuming another organization's program or clients Transferring program(s) or clients to another organization Looking for a collaboration Other (please explain) Done
