Name of Organisation   

Address   

Contact Person   

Contact Number   

Fax Number   

What does your organisation do?   

What organisations does your organisation work with?   

What would you like your organisation to do in future?   

What resources have you got (example) office, phone, etc?   

How would you like a Coalition to assist you?   

How could you assist the Coalition?   

What is the approximate budget of your organisation this year?   

Number of Full time workers   

Number of Part time workers   

Number of Volunteers   

Names of the funders of your organisation