SEPA Nonprofit Organization Application Updated on: January 17, 2023Thank you for your interest in hosting a SEPA Intern. Agency Name Primary Contact Email PhoneAddress Street Address City State / Province / Region ZIP / Postal Code Year Founded Please provide a description of the agency’s mission and responsibilities:What geographic region does the agency serve?How many people does the agency serve?Indicate a specific program or project you will focus on during the workshop and the summer internship. (We find the program works better if the agency has a specific project or grant in mind.)How many grant applications did your agency submit in 2022? How many grant applications did your agency submit in 2021? Have you previously been a SEPA agency partner? Yes No Does your agency have a dedicated office or workplace where the Intern will serve? Yes No If yes, please provide the address (if different from above). Street Address City State / Province / Region ZIP / Postal Code If no, please describe your plan to meet with and support the Intern during the summer.Does your organizations have the following documents or policies readily available:1) Business/Organizational Charter or your State official Incorporation Documentation ‐ (Through your state Secretary's Office) Yes No 2) A Federal Tax Identification Number (EIN) Yes No Third Choice 3) IRS Letter of Determination confirming 501c3 status Yes No 4) Governance Structure (typically an organizational chart) Yes No 5) Board Roster Yes No 6) Organizational Bylaws Yes No 7) Key staff roster and brief bios and/or job descriptions Yes No 8) Mission & Vision Statements Yes No 9) Employee Policies and Procedures Yes No 10) Volunteer Policies and Procedures Yes No 11) Strategic Plan Yes No 12) Organizational and programmatic description(s) for every program offered Yes No 13) Annual organizational budget Yes No 14) Programmatic budget(s) for every program offered. Yes No 15) Fiscal policies and procedures Yes No 16) Financial statements for prior 2-3 years (could include 990 tax returns, profit and loss statements, bank statements, etc.) Yes No 17) Audited financial statements (or financial statements for organizations with budgets below $300,000) Yes No 18) List of current and previously funded grants Yes No 19) Grants Management Processes and Controls Yes No 20) Community relationships list with descriptions of partnerships Yes No 21) A list of any and all consultants (that will work with the proposed program or project) Yes No Upload a copy of your IRS letter of determination*Accepted file types: pdf, doc, docx, jpg, Max. file size: 50 MB.Please confirm that you agree to the following conditions of the program by checking the boxes next to the statements:*Please note that we also recognize the possibility that vaccines will reach us in time to alleviate all these concerns. I confirm that a representative of my agency or I will attend the grant writing workshop in Summer 2023. Dates will be late May or early June. I confirm that I am willing to supervise the student and to provide them with adequate hands‐on opportunities to work in project development, research, and grant writing. I agree to participate in a post‐program survey and discussion forum to help us evaluate the program. I agree to inform SEPA staff of the outcome of any grants submitted by the Intern.