KTnB Affiliate Application Survey

1.Contact Information(Required.)

Main Contact Name

City, County or Region

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

2.Shipping Address, If different from above

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

3.What is estimated population of proposed affiliate?

4.Highest Elected Official

Name:

Title:

Date Contacted:

5.Are you applying on behalf of an existing organization or government committee/commission? If so, please list the name.

6.Please identify the organizational structure of the existing organization, if applicable.

Other (please specify)

7.Affiliate Fee Commitment:
We agree to either pay an annual fee of $150 OR document 8 hours of volunteer time for cleanup, fixup or beautification of community with 12 months.

Option 1: Send a check for $150
Keep Tennessee Beautiful
The University of Memphis
976 West Park Loop, Suite 113
Memphis, Tennessee 38152

Option 2: Document Eight (8) Volunteer Hours by one or more individuals in space below

Please provide the number of volunteers, the number of hours, and a brief description of the cleanup, fixup, beautification, or educational project(s) in the past twelve months.

8.Provisional Affiliate Requirement Acknowledgement:
With the acceptance of the application, the applicant will move into Provisional Affiliate status. Over the next 3 months, Provisional Affiliates are required to complete the items below with assistance from KTnB.

Determine the organizational structure and board membership (committee of an existing organization encouraged)
Agree to use the name Keep “Name” Beautiful if a newly forming organization but not required of organizations with an established identity
Prepare mission statement
Prepare bylaws, organization guidelines, ordinance, and/or resolution for the organization
Conduct a community needs assessment
Establish a budget; this may be in-kind

By typing your name you acknowledge you have read and understood the Provisional Affiliate steps.

9.Annual Affiliate Requirments Acknowledgement:
Each affiliate must complete the following requirements each year between July 1 and June 30:

Submit $150 Annual Dues or document equivalent volunteer time 8 hours
Participate in Tennessee Great American Cleanup and at least ONE approved activity every year such as
- Nobody Trashes Tennessee promotion
- Arbor Day Celebration
- Make A Difference Day
- Environmental Education (including reading book Nancy and Sluggo Love Tennessee at a school or youth event)
- Keep TN River Beautiful Waterway Cleanup Event (including International Coastal Cleanup)
- America Recycles Day Event
- Recycling and/or Reuse Collection
- Can You Dig It including tree and/or flower planting
- Participate in Ready, Set, Grow 5-K Run
- Participate in Litter Law Enforcement Education Program
Attend a minimum of 4 hours of training during the KTnB Biennial Conference or Affiliate Retreat, at a KTnB regional workshop, a Webinar, other training provided through KTnB or its partners.
Submit an Annual Survey and Report with general information about includes the number of volunteers and volunteer hours

By typing your name you acknowledge you have read and understood the Annual Affiliate requirements.

KTnB Affiliate Application

Instructions