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1-800-269-4668 1401 West Capitol Suite 170, Little Rock, AR 72201

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Provisional Membership Application

Programs seeking membership in the Arkansas Coalition Against Domestic Violence (ACADV) must complete the following application. Please answer all questions completely and attach the required documentation.

Feel free to include material that would be helpful in explaining your program.

1. Name of Organization
  Zip Code
  Business Phone
  Contact Person
  Email Address
  You will receive the ACADV newsletter at the above email address unless you check the box to have it mailed to you. Yes, please mail the newsletter to the above address
2. Are you a nonprofit organization? Yes No In process
  Date of incorporation

3. Do you have a 501(c)(3) Federal Tax Exempt Status? Yes No In process
4. Give a brief chronological history of your organization. How did it get started? When? By whom? Why?
5. What provisions has your program developed to include battered/formerly battered women in all aspects of the organization (i.e., Board of Directors, Advisory Board, Staff, Volunteers)?
6. How is the organization governed (i.e., Board of Directors, Advisory Council, etc.)?
7. How and by what authority are policy decisions made?
8. How often does your governing body meet?
9. How are members selected?
10. How does the membership of the governing body reflect the racial and ethnic composition of the community served by your organization? Please include a racial and ethnic profile of your community.
11. Does the governing body include battered/formerly battered women? Yes No
  If yes please describe. If no, why not?
12. Please list any affiliations or associations with other local, state or national organizations. What requirements or constraints do those relationships place upon your organization's actions?
13. How many paid staff do you have? Full time Part-time Women
14. What role, if any, do volunteers play in your organization?
15. Briefly describe your organization's purpose and goals.
16. Describe the services your organization is currently providing.
17. Do you have specific plans for new or expanded services/programs? Yes No
  If yes, please describe.
18. Describe your relationship with ACADV member programs in your community or surrounding counties.




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1401 West Capitol Ave, Suite 170, Little Rock, AR 72201