Arkansas Coalition Against Domestic Violence :: Provisional Membership Application

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ACADV Membership Application

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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
	Address
	City
	Zip Code
	County
	Business Phone
	Fax
	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
	Date
4.	Give a brief chronological history of your organization. How did it get started? When? By whom? Why?
Structure/Staff
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?
Program
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.