Incorporation Form

Community Counsel Program

Incorporated Group Client Application

Name of Corporation:

*

State of Incorporation:

*

Year Incorporated:

*

Check all that apply:

Not-For-Profit

Tax-Exempt

Address:

*

City:

*

State:

*

Zip Code:

*

Telephone:

*

Fax:

E-mail:

Contacts:

Primary Contact:

Primary Contact Phone #:

Primary Contact Address:

Primary Contact City:

Primary Contact State:

Primary Contact Position/Office:

Primary Contact E-mail:

Secondary Contact:

Secondary Contact Phone #:

Secondary Contact Address:

Secondary Contact City:

Secondary Contact State:

Secondary Contact Position/Office:

Secondary Contact E-mail:

Purpose of the Corporation:

*

Geographic Target Area:

County:

Does the Corporation serve primarily low income people?

Yes
No

Is the Corporation financially unable to retain and pay for a private attorney?

Yes
No

Does the Corporation have any board members who are attorneys?

Yes
No

If so please list:

Has the Corporation retained and paid an attorney in the past 12 months?

Yes
No

If so please list:

Approximate number of clients the Corporation serves annually:

General Statement of problem:

How did you learn about the Community Counsel Program?

I certify that the above information is correct and I am authorized to file this Application.

By:

*

Office/Title:

*

Date:

*

Signature (Print Name):

*

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