Application for United Way's Bus Pass Program January - March 2018 Distribution. This application must be completed by Thursday, December 14, 2017. Organization Name * Address * City * State * Zip Code * County * Telephone Number * Tax ID Number * Has your organization submitted a copy of IRS 501(c)(3) status? * Yes No Please attach a copy of your organization's 501(c)(3) status Files must be less than 2 MB.Allowed file types: gif jpg png txt rtf html pdf doc docx odt ppt pptx odp xls xlsx ods xml. Organization Must provide services in one of the following areas * Health Education Income and Basic Needs Person responsible for reporting bus pass data to United Way of the Mid-Willamette Valley? Name * Phone * Email * Application Prepared By? Name * Title * Phone * Applicant Email * Authorized individual(s) to pick up allotted passes? * Pick a maximum of three people that are authorized to pick up passes. Organization Narrative..Answer each question as a response in your narrative. Answers should be no more than 500 words/ What is your organization’s overall mission and core values? * Who receives your organization’s services? (Please be as specific as possible) * Please name and describe the programs within your organization that will distribute the bus passes * Has your organization received bus passes from United Way of the Mid-Willamette Valley in the last year? * Does your organization purchase passes from Cherriots directly? If so, how are the purchases funded? * List the top 5 reasons bus passes are needed by your clients * Total Number of Adult (18+ years) Go Cards Requested: * Total Number of Youth (under 18 years) Go Cards Requested * Agree to terms * Yes My organization meets the eligibility criteria for United Way's Bus Pass Program, and will use bus passes as intended. Our Bus Pass Tracking Form will be submitted in a timely manner.