Workership Application

Application for Workership Funding

Applicant: (required)

I. Applicant Information

1. Is the applicant organized as a not-for-profit organization under state laws governing
charitable organizations?
yesno

If yes, in what state or commonwealth?

If no, please explain

2. Has the applicant received a ruling or determination letter from the Internal Revenue
Service about the following?

(a.) Exempt Status
yesno

(b.) Private Foundation Status
YesNo

(c.) Municipal Body: Town, Village, County, etc.
YesNo

(Attach a copy of each such letter, if you have NOT submitted a copy in the past.)

3. Is the applicant controlled by, related to, connected with or sponsored by another
organization?
YesNo

If yes, please attach a statement to this application identifying the organization, its
purpose and activities and its relationship to the applicant.

4. Please attach a list with the name, address, and title of each member of the applicant’s governing board./////

5. Name the person who will be administering the workership program . This is the
person that will be receiving and dispensing the workership monies.

Administer Name

Administer Title

Administer Street Address

Administer City, State, Zip Code

Administer Area Code and Telephone #

Administer E-Mail Address

6. Has the applicant (or any organization listed in #4 above) ever applied for or received a grant from the Pratt Northam Foundation in the past?
YesNo

II. Description of Workership(s)
1. List each workerhsip requested (by job title) and the total number of hours of work for each (ie. 400 hrs., 300hrs., 200hrs., 150hrs., 100hrs., etc.). [Maximum: 400 hours]
Job 1 - Job Title, Hours of Work, Description

Add Another Job

Add Another Job

Add Another Job

Add Another Job

2. Will the workership student be receiving college-credit for doing this work?
YesNo

Please attach documentation from the college confirming this credit.

3. Will the workership student provide programming directly to youth?
YesNo

Will the workership student provide indirect support to a youth program?
YesNo

4. Explain how in the selection, training and supervision for this workership position, the applicant will insure a quality work experience for a college student attempting to build a career path through this summer work?

5. Will the student filling this position be a member of the immediate family of a member
of the applicant’s governing board or a person employed by the applicant?
YesNo

If Yes, explain:

7. Contact information for immediate supervisor for each position:

Job Title:

Position 1 Name

Position 1 Title

Position 1 Street Address

Position 1 City, State, Zip Code

Position 1 Area Code and Telephone #

Position 1 E-Mail Address

Job Title:

Position 2 Name

Position 2 Title

Position 2 Street Address

Position 2 City, State, Zip Code

Position 2 Area Code and Telephone #

Position 2 E-Mail Address

III. Certification

From my own knowledge, I state that the information given in Parts I and II is accurate.
The applicant organization has authorized me to make this application.

Signature
[signature* signature-applicant class:signature cols:350 rows:50]

Printed Name
[signature print-name class:signature cols:350 rows:50]

Title

Date

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