2015 InterAction Membership Application

Transcription

1 2015 InterAction Membership Application 1. ORGANIZATION NAME: NAME OF THE CEO: ADDRESS: TELEPHONE: 2. CONTACT PERSON: ADDRESS: TITLE: 3. ADDRESS: 4. TELEPHONE: 5. FAX: 6. ADDRESS: 7. WEBSITE: 8. YEAR FOUNDED: 9. INCORPORATED IN THE STATE OF: 10. STATEMENT OF ORGANIZATIONAL PURPOSE: Page 1 of 6

2 11. BRIEFLY DESCRIBE THE ORGANIZATION S PROGRAMS. INCLUDE A LISTING OF THE LOCATION OF FIELD OFFICES OR REGIONAL OFFICES WORLDWIDE. (ATTACH MATERIALS, IN ADDITION TO YOUR ANNUAL REPORT, AS APPROPRIATE): 12. WHY DOES YOUR ORGANIZATION WISH TO JOIN INTERACTION AND HOW WOULD YOU AND YOUR STAFF EXPECT TO PARTICIPATE? Page 2 of 6

3 13. DESCRIBE YOUR GOVERNANCE STRUCTURE: a) INDEPENDENCE OF YOUR BOARD b) SIZE OF BOARD AND EXECUTIVE COMMITTEE c) FREQUENCY OF MEETINGS d) DOES ANY BOARD MEMBER RECEIVE COMPENSATION FOR HIS/HER WORK ON THE BOARD? e) DOES THE BOARD APPROVE YOUR BUDGET? 14. NUMBER OF FULL-TIME, SALARIED STAFF IN THE U.S.; OUTSIDE THE U.S.: 15. DOES YOUR ORGANIZATION HAVE AN EMPLOYMENT POLICY REGARDING STAFF GENDER, MINORITY REPRESENTATION AND INCLUSION OF PEOPLE WITH DISABILITIES? (With minority we mean a racial, religious, political, national, or other group that has a small representation relative to the larger group of which it is part). Number of senior staff positions held by women: Titles: Number of senior staff positions held by minorities: Titles: Number of staff positions held by people with disabilities: Titles: Page 3 of 6

4 16. LIST THE NAME AND TITLES OF YOUR CHAIRPERSON OF THE BOARD OF DIRECTORS AND EXECUTIVE COMMITTEE MEMBERS: 17. DOES YOUR BOARD HAVE A POLICY REGARDING BOARD GENDER AND MINORITY REPRESENTATION? (With minority we mean a racial, religious, political, national, or other group that has a small representation relative to the larger group of which it is part) Number of board positions held by women: Number of board positions held by minorities: 18. DOES YOUR ORGANIZATION HAVE THE FOLLOWING WRITTEN POLICIES? a) Conflict of interest policy b) Whistleblower policy c) Document retention and destruction policy 19. PLEASE LIST AT LEAST THREE PVOs WITH WHICH YOUR ORGANIZATION HAS WORKED IN THE LAST TWO YEARS, AND DESCRIBE THE COLLABORATION / AFFILIATION: Page 4 of 6

5 20. DO YOU WORK WITH PARTNER ORGANIZATIONS OVERSEAS? PLEASE DESCRIBE THE MANNER IN WHICH YOU IMPLEMENT PROGRAMS TOGETHER AND WHERE: 21. PLEASE INDICATE THE APPROXIMATE AMOUNT OF THE FOLLOWING FUNDING SOURCES AS A PERCENTAGE OF YOUR TOTAL ANNUAL INCOME: Federal Grants: % Federal Contracts: % Foundation Grants: % Membership Dues: % Contributions: % Explain the source: (E.g. individual/public, corporate giving) Others: % Explain: Required application materials: - Completed Application - By-Laws - Articles of Incorporation - IRS Letter of Tax Exempt Status - Most recent Annual Report - Most current Audited Financial Statement - Current Year s budget as Approved by the Board of Directors - PVO Standards Review Form - Three letters of recommendation from Three current InterAction members Page 5 of 6

6 Calculation of international expenses International expense is defined as that amount spent toward the accomplishment of your international work. If all of your work is international, you will have no domestic expense, and will be assessed on your total expense. If you have domestic programs (programs delivered relating to poverty or relief issues in the U.S.), you would subtract both the program expense for those programs and whatever portion of your overhead is attributable to those programs. An example follows: Statement of International Expenses Total expense from financial statement $3,500,000 Domestic expense 1,500,000 International expense 2,000,000 Gifts-in-kind (international) 800,000 Pass throughs to IA members (international) 100,000 Net assessable international expense $1,100,000 In order for your potential dues to be calculated, please visit the following link (start by creating a login) and complete the form so that the Membership team can estimate your dues Application submission deadlines: January 12, 2015 April 20, 2015 July 6, 2015 October 5, 2015 Page 6 of 6