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C3 Workshop Required Questionnaire
1. Default Section
1
. Please provide the following information about you and the organization you represent.
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 Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP/Postal Code:
County:
Email Address:
Phone Number:
2
. Please provide the following information about your organization.
Please provide the following information about your organization.
Website:
Fax Number:
3
. Please provide the names of individuals registering for the workshop on Feb. 4, 2010.
Please provide the names of individuals registering for the workshop on Feb. 4, 2010.
1.
2.
3.
4.
5.
4
. Please state your organization's purpose or mission.
Please state your organization's purpose or mission.
5
. When was your organization established?
When was your organization established?
6
. Select areas served by your organization (check all that apply).
Select areas served by your organization (check all that apply).
Lexington County
Richland County
Other (please specify)
7
. What type of services are provided by your organization? (Check all that apply.)
What type of services are provided by your organization? (Check all that apply.)
Social Services
Arts/Culture
Education
Healthcare
Other (please specify)
8
. What is your organization's current fiscal year's budget?
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
9
. Is your organization affiliated with a national organization?
Is your organization affiliated with a national organization?
Yes
No
If yes, please name national organization
10
. Current funding sources for your organization are: (Check all that apply.)
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
11
. Is your organization currently in discussions with one or more other organizations for new collaborations?
Is your organization currently in discussions with one or more other organizations for new collaborations?
Yes
No
12
. What type of assistance are you looking for?
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)
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