* Denotes a required field
*Name of your organization (as registered with Florida Division of Corporations' Sunbiz website):
*If not chartered in Florida, please explain:
*Is your organization tax exempt under section 501(c)(3) of the IRS code?
*Did your organization file an IRS Form 990, 990EZ or 990N for your most recent fiscal year?
*Provide your EIN:
*Date of incorporation (applicants must be in operation for at least one calendar year):
*What was as your 2018 operations budget?
*Has your agency received funding from Orange County Citizens' Commission for Children in the past?
*Physical address/location:
*Mailing Address (if different from physical address):
*Phone number:
*Fax number:
*Do you have computer hardware, software and internet connections to allow participants to access the online course?
*Chief executive name:
*Chief executive title:
*Chief executive phone:
*Chief executive email:
*President name:
*President title:
*President phone:
*President email:
 Designated point of contact name:
 Designated point of contact title:
 Designated point of contact phone:
 Designated point of contact email:
*Organization mission statement (formal or informal):
*Board members #:
*Full-time paid staff #:
*Part-time paid staff #:
*Full-time volunteers #:
*Part-time volunteers #:
*Clients (unduplicated) served in your fiscal year 2018 #:
*Total number of programs currently offered (identify in narrative description):
*Total number of years programs have been offered:
*Cover letter (include why this type of training would be beneficial to your agency at this time, brief organization overview, programs/services offered, service area, current funders, etc.):
*Board of directors list (Name/Position on Board/Term beginning and end date/Community (business) affiliation/electronic contact information):
*2018 Statement of Activities (Revenue and Expense Statements):