2009-2010 Collaborating Agency Application

Name of Agency: Place of Faith   Non-Profit   Not-for-Profit   Private   Government     Agency's mission: Address 1   Address 2   City: State: zip:   Contact Name Title   Work days/hours   Phone Cell Phone Fax Email Web Site 1. Is this your first year with Gifts for Seniors?   yes 2. I prefer to receive program updates by: Email or FAX    3. Indicate the estimated number of isolated seniors you hope to serve through the GIFTS FOR SENIORS program.         a. What percent are: Women? %    Men? %    4. I am available to be interviewed regarding GIFTS FOR SENIORS by media:  Radio  Newspaper  TV Please be aware that the Sunshine Club is currently unavailable. Submit  Cancel