Partner Organization Application

Partnership Details

Describe Your Organization's Mission & How You'd Like to Partner *

Target Population Served

Geographic Service Area

Number of Active Volunteers / Members

Annual Operating Budget (optional)

Partnership Agreement & Authorization

By submitting this application, the authorized representative confirms that the information provided is accurate and that their organization is interested in exploring a formal partnership with Bridging The Gap; CommunityCare Solutions, Inc. Submission of this application does not constitute a binding agreement.

I confirm that I am an authorized representative of the organization listed above and that all information provided is accurate to the best of my knowledge. *

Authorized Signature (Type Full Name) *

Electronic signature

Title

Date

Organization & Partnership Information

Organization Information

Primary Contact

Partnership Interest *

Partnership Details

Partnership Agreement & Authorization