Statement of Interest

Statement of Interest Form
Thank you for your interest in United Way of the Mid-South. Please complete the information below. If you have questions, please contact Janet Haas at janet.haas@uwmidsouth.org
Today's Date

Month Day Year
Date Hour Minutes AM/PM Option
AGENCY INFORMATION
Name of Agency *
Physical Address *

Street Address

City State

Zip Code
Mailing Address (if different from physical address)

Street Address

City State

Zip Code
Executive Director *

First Name Last Name
E-mail *
Phone Number

Area Code Phone Number
Website?
Which county(ies) do you serve? *

Crittenden DeSoto Fayette Lauderdale Marshall Shelby Tate Tipton Tunica
Are you tax exempt under section 501(c)3 of the Internal Revenue Service Code?*

Yes No
Please indicate the Area(s) of Service your agency provides:

Adult Disability Services Adult Education and Training Alcohol and Drug Children 0-5 Crisis Intervention/Hotline Disabilities 0-5 Domestic Violence Emergency Assistance - Material, Food, Rent/Mortgage, Utilities Emergency Housing/Homelessness Financial Literacy/Housing Education Foster Care Health and Wellness Education HIV/AIDS Services/Education Homelessness/Housing/Community Development Immigrant Services Information and Referral Job Readiness/Training Literacy Mental Health - Adult Mental Health - Youth Mentoring Physical Health Senior Services Volunteer Youth Education/Training Youth Recreation
Please describe the target population receiving your service(s) and the issue or opportunity your service addresses. *
Should be Empty:

Statement of Interest Form