Date:
Name of Organization:
Street Address:
City:
State:
Zip:
County:
Contact Person:
Title:
Daytime Phone:
Fax:
Email: *Required	(Ex: email@yoursite.com)
Employees:
Independent Contractors:
Agency Status:
501(c)(3) 501(c)(4) Other: Advanced Ruling Permanent Application
Incorporation Date:
Fiscal Year End:
Current Year Budget:
The organization's total contributions from the past year?
Have you had a compilation, review, or audit?	Yes No
Have you had a compilation, review, or audit? If so, when?
Do you currently have a person providing bookkeeping/accounting services?	Yes No
Community Accountant services you are interested in: Direct Service (for nonprofit organizations with budgets under $250,000) Workshops Publications Ask an Accountant Community Accountants on Boards & Committees (CABC) Referrals
Comments/Questions:
Please enclose any information relevant to your organization, i.e. programs and list of board of directors. Include newsletter, brochures, annual report, news releases, flyers, written descriptions, etc.
How did you hear about Community Accountants? Radio/TV Referral by: Newspaper Press Web site Other: