TS Inquiry Form

Name of Organization * Address * City * State * Zip Code * Website Name of Person Filling out Application * Title of Person Filling out Application * Telephone Number * Email Address * Fax Mission Statement * Programs/Services Target Population(s) Please check one or all that apply: Low-income Children and Youth Women Mentally Ill Physically Ill or Disabled Immigrants Seniors Men Racial/Ethnic Minorities Other Population Number of Staff: Full Time Number of Staff: Part-Time Number of Clients Served Annually Annual Budget Is your organization a current or former grantee of the William Penn Foundation? * yes no If Yes, list the year and purpose of your most recent grant. Interests Please check the general Service Areas that your organization is interested in: Organizational Development Strategic Planning Board Development Environmental Scan Interim Executive Management Financial Management Information Systems/Technology Research and Evaluation Program Design and/or Evaluation Logic Models and Outcomes Measurement Data Collection and Analysis Focus Groups/Interviews Marketing and Communications Website Development Video production Program/Agency Literature LGBT Issues Other Needs In two or three sentences, describe your specific technical assistance or capacity building need in the area(s) selected: How did you hear about Targeted Solutions? Additional Questions or Comments: