2018 MEMBERSHIP APPLICATION & PROFILE

Transcription

1 P.O. Box 8622, South Charleston, WV (Internal Use) Organization Number 2018 MEMBERSHIP APPLICATION & PROFILE Storehouse Member Building Material Member Today s Date: 1. Organization Name Street Address Mailing Address City State WV Zip Office Phone Fax Website URL WV Congressional District Organizational Annual Budget WV Senate District Federal I.D. # State Tax Exempt # Organization Chief Executive CEO Title CEO Phone CEO 2. Primary Contact Person for Storehouse Position / Title with Organization Mailing Address Work Phone Home Phone Cell # 3. Additional Authorized User(s) Information: Name Phone Work Phone Home Cell Phone 4. Name Phone Work Phone Home Cell Phone Home County Other Counties Served (Please Circle) Barbour Boone Brooke Calhoun Berkeley Braxton Cabell Clay Doddridge Fayette Gilmer Grant Greenbrier Hampshire Hancock Harrison Jefferson Lewis Logan Marshall McDowell Mineral Monongalia Monroe Nicholas Hardy Jackson Kanawha Lincoln Marion Mason Mercer Mingo Morgan Ohio Pendleton Pleasants Pocahontas Preston Putnam Randolph Roane Taylor Tyler Wayne Wetzel Wood Raleigh Ritchie Summers Tucker Upshur Webster Wirt Wyoming

2 P.O. Box 8622, South Charleston, WV WHAT DOES YOUR ORGANIZATION DO? Provide a brief overview of your agency s mission & mission statement WHO DO YOU SERVE? Provide a brief description of the population your organization serves. HOW MANY PEOPLE DOES YOUR AGENCY REACH? Please provide an estimation of the number of people served over the last 12 months: Circle the groups you primarily work with: CHILDREN ELDERLY MEN WOMEN OTHER (List) How will you use the items received to help the group(s) circled above Where will you store the products received? WHAT DO YOU NEED? Provide a brief list of the types of donated product that would be most useful to your organization. I have read, understand, and agree to comply with the attached Member Agency Release Agreement. I realize that our membership could be terminated if I am in violation of any of the listed requirements. I will attach a copy of our 501 (c)(3) federal tax Determination letter or church By-Laws. Executive Director (Pastor) Signature Date

3 P.O. Box 8622, So. Charleston, WV MEMBERSHIP AGENCY RELEASE AGREEMENT If our Storehouse West Virginia TM Application is approved we agree to the following: 1. Merchandise received from the Storehouse WV must be used by the organization solely for the care of the ill, the needy, or minors. And agrees to honor the following uses of donated products: Your organization must not sell, trade, barter, or otherwise transfer any donated goods in exchange for money, property, or services. Prohibited transfers include listing the donated goods for sale or trade on websites, in stores, at flea markets, or in any similar manner. Your organization must not use donated goods for raffles, auctions, or any fundraising activity. Your organization must not accept anything of value (including voluntary donations) in exchange for the donated goods. Your organization must not give any donated goods to its volunteers, officers, directors, employees, or contractors for personal use. Your organization must not return any donated goods to the manufacturer or to any retail store. Your organization must not give donations to another nonprofit organization or other entity. Your organization must not redistribute any donated goods to any location outside of West Virginia. 2. The Organization understands and agrees that any Donated Goods the Organization may receive from Storehouse WV will be received by the Organization in as-is condition, with all faults and defects, latent and otherwise. Storehouse WV makes no warranty, covenant or representation, expressed or implied, or arising by operation of law, regarding Donated Goods, including without limitation, any warranty as to their design, condition, merchantability, or fitness for any particular use or purpose. Storehouse WV shall not be liable in any event for any direct, actual, special, indirect, incidental or consequential damages or losses of any kind, nature or description whatsoever, regardless of whether arising from breach of contract, warranty, tort, strict liability or otherwise, suffered or incurred by the Organization or a third party as a result of the transfer, receipt, storage, transportation or use of Donated Goods, even if the other party is advised of the possibility of such loss or damage or if such loss or damage could have been reasonably foreseen. 3. The Organization hereby fully releases and discharges Good360 from and waives any and all rights, claims, and actions that Organization may have or acquire against Good360 arising out of or in any way associated with Donated Goods, including, without limitation, the condition, use, or consumption of Donated Goods. The Organization specifically intends to and does release, discharge and waive all such rights, claims, and actions against Good360, whether known or unknown, suspected or unsuspected, contingent or non-contingent, and without regard to the later discovery of other, additional, different, or currently unknown or unanticipated facts, including but not limited to facts at odds with those which the Parties now believe or anticipate to be true. 4. The Organization understands and agrees that the Organization is solely responsible for the correct storage, transportation (after receipt by the Organization) and disposal of Donated Goods. The Organization shall store, transport and dispose of Donated Goods in accordance with the applicable manufacturer instructions and guidelines, all applicable laws, ordinances, and regulations relating to the storage, transportation and disposal of Donated Goods, and highest industry standards. 5. The Organization shall store Donated Goods, and distribute Donated Goods from, a business location. 6. The Organization agrees to maintain adequate books and records reflecting merchandise received from Storehouse WV and, if requested, to provide Storehouse WV and/or the Internal Revenue Service with substantiation of its use and distribution of such merchandise. The Organization shall keep such books and records for at least four (4) years after the end of the year of the receipt of such Donated Goods, or for such longer period as may be required by applicable federal, state, or local tax regulations. 7. The Organization will notify Storehouse WV promptly of any change in its status for federal tax purposes. 8. The Organization agrees to have their name and/or photo listed as members of Storehouse West Virginia TM in any internal or external documents. 9. The Organization agrees to provide periodic reports on how donated products are being used. (Accompanying pictures would be appreciated.)

4 Suggested Partnership Donation Schedule Organization Address In addition to donating the required Registration fee, Storehouse Members can choose to be a Storehouse Partner and make an annual donation based on agency s annual budget (see below). The benefits of being a Storehouse Partner: * Partners are notified first when new General Product arrives, and are given a week, or so, to make distribution appointments before other Members are notified. * When limited quantities of certain products are received they may be set aside for Storehouse Partners. YEARLY BUDGET Annual Suggested Donation Schedule Suggested Donation Budgets under $50, per year $ Budgets between $50,000 - $99, per year $ Budgets between $100,000 - $299, per year $ Budgets between $300,000 - $499, per year $ Budgets between $500,000 - $799, per year $ Budgets over $800, $1, SUGGESTED DONATION CALCULATION WORKSHEET ORGANIZATION S ANNUAL BUDGET $ SUGGESTED ANNUAL DONATION $ ANNUAL REGISTRATION FEE $ Person Completing Form TOTAL DONATION AMOUNT $ CHECK NUMBER Annual partnership gift will be renewable one year from application date. Renewal Date Donations should be made out to Believe in WV Storehouse. For Office Use Only: Mail Donations to, P.O. Box 8622, South Charleston, WV 25303

5 P.O. Box 8622, So. Charleston, WV APPLICATION COMPLETION CHECKLIST: 1. Completed Application and Membership Profile, including Member Agency Release Agreement 2. Copy of 501(c)3 determination letter; church bylaws; or letter from denominational main office 4. $200 Storehouse Member Annual Donation Or 5. $25 Building Materials Member Annual Donation 6. Optional Storehouse Partnership Donation Schedule & Donation Mail Membership Application Profile, signed release, 501 (c) (3) letter, and donation to: Believe in WV - Storehouse P.O. Box 8622 South Charleston, WV Or bring to Storehouse West Virginia TM during days we are open, at: 1313 Hansford Street, Charleston, WV For Internal Use: Date Reviewed Status Missing Documents: Determ. Ltr ByL Don Organization Number VR OL Date Notified