Partner Intake Form - Imagine with a Mission

Partner Intake

Thank you for your interest in partnering with Imagine With A Mission. Please complete the following intake form for consideration as a community partner. Thank you!

Community Partner - General Information

Legal Business Name

Business Address

Business Email Address

Business Phone Number

State of Incorporation

Federal ID/EIN #

Community Partner - Main Point of Contact

Full Name

Title

Cell Phone

Email Address

Personal Address

List all owners - please note that a resume/curriculum vitae (CV) must also be attached for each owner.

Owner 1 - Full Name

Owner 2 - Full Name

Owner 3 - Full Name

Owner 4 - Full Name

Community Partner - Employees

List all key employees and provide a brief job description of each

Employee 1 - Full Name

Employee 1 - Job Description

Employee 2 - Full Name

Employee 2 - Job Description

Employee 3 - Full Name

Employee 3 - Job Description

Employee 4 - Full Name

Employee 4 - Job Description

Community Partner And/or Owner Current or Pending Litigation

Does the Community Partner have any current or pending litigation?

Yes No

If yes, please provide a description of the current of pending litigation:

Do any Community Partner owners have any current or pending litigation?

Yes No

If yes, please provide a description of the current of pending litigation:

COMMUNITY PARTNER - INSURANCE

List the name of the insurance agency that the requesting entity is insured with - please note that an insurance declarations page showing all types and amounts of insurance coverage must be submitted.

Name of Insurance Agency:

COMMUNITY PARTNER - A POTENTIAL PARTNERSHIP WITH IMAGINE WITH A MISSION

Identify the IWAM project for which the Community Partner seeks funding:

Identify the duration of the project:

Name the skills and expertise (e.g. construction, counseling, tutoring) of the Community Partner:

Provide information of any relevant experience with similar projects:

Provide three relevant references for projects completed by the Community Partner:

Reference 1 – Full Name

Reference 1 - Title

Reference 1 - Phone Number

Reference 1 - Email

Reference 2 – Full Name

Reference 2 - Title

Reference 2 - Phone Number

Reference 2 - Email

Reference 3 – Full Name

Reference 3 - Title

Reference 3 - Phone Number

Reference 3 - Email

COMMUNITY PARTNER – BUDGET REQUESTED

Identify the total amount of requested funding:

Identify the total amount of funding needed in the first 90 days of the project:

Identify the monthly funding amount needed each month after the first 90 days of the project:

Provide a budget breakdown – specify how the requested funding will be used:

Provide estimated timelines for any project milestones:

COMMUNITY PARTNER – JUSTIFICATION

Describe why the Community Partner’s mission aligns with the goal of the IWAM project:

COMMUNITY PARTNER - CHECKLIST OF DOCUMENTS NEEDED FOR SUBMISSION (Please submit only pdfs)

Resume/CV of all owners Financial statements for the most recent fiscal year Insurance declarations page showing all types and amounts of insurance coverage Any other supporting documentation regarding budget, timeline, or partner mission alignment with IWAM

Resume/CV of All Owner 1

Resume/CV of All Owner 2

Finacial Statements for the most recent fiscal year

Insurance declarations page showing all types and amounts of insurance coverage

Any other supporting documentation regarding budget, timeline or partner mission alignment with IWAM