Please complete the following survey for each proposal.

Organization Head Quarters

Organization Name *

Organization Head Quarters Address *

Organization Head Quarters Address Line 2

City *

State *

Zip Code *

American Job Center (AJC)

AJC Site Proposing Address *

AJC Site Proposing Address Line 2

City *

State *

Zip Code *

Amount Adult Requested *

Amount Dislocated Worker Requested *

Amount Youth Requested *

CEO / Executive Director

CEC / Executive Directors First Name *

CEO / Executive Directors Last Name *

CEO / Executive Directors Email Address *

CEO / Executive Directors Phone Number *

What is the race/ethnicity of your organization's ED/CEO or equivalent? *

If you answered other or biracial and wish to share more information, please do so here:

Organization Demographics

Total Number of Employees *

What percentage of your organization's staff leadership are Black or African American? *

What percentage of your organization's staff leadership are Latinx? *

What percentage of your organization's staff leadership are Asian? *

What percentage of your organization's staff leadership identify as other non-white racial/ethnic background? *

BOARD PRESIDENT

Board President First Name *

Board President Last Name *

Board President Email Address *

Board President Phone Number *

What is the race/ethnicity of your organization's Board President or equivalent? *

If you answered other or biracial and wish to share more information, please do so here:

BOARD TREASURER

Board Treasurer First Name *

Board Treasurer Last Name *

Board Treasurer Email Address *

Board Treasurer Phone Number *

What is the race/ethnicity of your organization's Board Treasurer or Equivalent? *

If you answered other or biracial and wish to share more information, please do so here:

BOARD OF DIRECTORS DEMOGRAPHICS

What percentage of your organization's Board of Directors are Black or African American? *

What percentage of your organization's Board of Directors are Latinx? *

What percentage of your organization's Board of Directors are Asian? *

What percentage of your organization's Board of Directors identify as other non-white racial/ethnic background? *

Primary Point of Contact for RFP

First Name *

Last Name *

Phone Number *

Email Address *