GoodNeighbor Partnership Application

GoodNeighbor Partnership Application

Organization Name*

Mailing Address*

City*

State*

Zip Code*

Organization Website*

Federal Tax ID Number*

Year Founded*

Number of Employees*

Number of people served each year.*

In what Wisconsin counties do you provide services?*

Select

Describe the mission of your organization and the services you provide.*

How would the GoodNeighbor program benefit your organization and the people you serve?*

Contact Name*

Contact Email*

Contact Phone Number*

Phone

Form Date Field*

Please check each box below to confirm eligibility and agree to terms based on Program Requirements.

Our organization is classified as a 501(c)(3) under the Internal Revenue Code.*

Our organization meets the program eligibility requirements.*

Our organization will comply with the GoodNeighbor Program Guidelines and Expectations.*

We understand that if we are removed from the program for noncompliance, a subsequent application will be required and if accepted, specific demographics on all distributed cards will be required.*

Please attach Nonprofit 501(c)(3) Certification.*

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