Professional Documents
Culture Documents
Agency Update Form & Invoice 14-15
Agency Update Form & Invoice 14-15
Phone
ext.
_______
Fax
*All update are sent via EMAIL. Please ensure that we have a current address and that your system is set up to
receive messages from us.
PLEASE PRINT OR TYPE CLEARLY. All information must be completed and returned for
continued service. Please fill out completely - our funders require this information.
Primary County
_______
____
____
____
____
____
____
____
____
Mental Health
Cognitive Disabilities
Substance Abuse/Recovery
Developmental Disability
Mobility Impairment
Blindness/Visual Impairment
Deafness/Hearing Impairment
Other: ______________________
Page 1
___
Name:
Title: __________________
___ Title: ___________________
Email:
_______
Email:
_______
Agency Description briefly state the general purpose and goals of your agency what you do, not your mission
statement.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Agency Certification
We certify that the information included in this agency update is true and complete to the best of our
knowledge.
Agency Director
Signature ___________________________
Signature _____________________________
Name ______________________________
Name ________________________________
(Please print)
(Please print)
Page 2
$___________________________
$_____________________________________
(Use sliding scale below to determine fee)
Up to$50,000
$50,001.................$100,000
$100,001.$250,000
$250,001...............$500,000
$500,001$1,000,000
$1,000,001.$1,500,000
$1,500,001............$2,000,000
$2,000,001.$3,000,000
$3,000,001............$4,000,000
$4,000,001.......... and above
$50.00
$75.00
$170.00
$175.00
$280.00
$300.00
$446.00
$557.00
$667.00
$686.00
VISA
MasterCard
Signature
____
(Please print)
Card Number