Name of Organization

Year Founded

Address

City

State or Province
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Zip or Postal Code

Mailing Address if different

Telephone
( ) -

Fax
( ) -

Federal 501(c)(3) Tax I.D. No.

Annual Budget (Minimum of $25,000 and maximum of $1,000,000)

Executive Director or Contact Person

Contact Phone
( ) -

Contact E-mail

Describe the history of your organization and its mission statement. (You may include Web sites or send brochures via mail.)

Describe briefly the services your organization provides, including the number of people served

Full Time Staff Members

Part Time Staff Members

Number of Volunteers

Total number of Board Members

Approximately what percentage of your funds comes from government sources?

If your organization received funds from the eWomenNetwork Foundation, how would you envision using the additional funds?