Pathways to Excellence Enrollment Form

Complete this form to start the Pathways to Excellence Enrollment process. You will need:

Basic agency information including service area, number of FTEs, and annual budget;
Agency strategic plan;
Board resolution supporting the pursuit of Excellence (Silver, Gold, and Platinum tiers only); and
Most recent 990 form (Silver, Gold, and Platinum tiers only)

The Partnership will use the information provided to start your enrollment process and generate an invoice for appropriate fees. Please note that enrollment is not complete until payment is received.

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* 1. Agency Name

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* 2. Agency Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

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* 3. Executive Director Name

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* 4. Primary Contact Information

Name

Email Address

Phone Number

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* 5. Type of Organization

Public

Private / Non-Profit

Hybrid Public / Private Non-Profit

Tribal Organization

Other CSBG Eligible Entity

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* 6. Total Agency Revenue

Amount of total Agency Revenue (from line 12 of most recent IRS Form 990)
If your agency is a public CAA, please provide your agency budget

IRS 990 Form Year
If your agency is a public CAA, please provide the agency budget year

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* 7. Number of full-time equivalent staff (FTEs)

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* 8. Pathways Enrollment Level

Bronze

Silver

Gold

Platinum

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* 9. Strategic Plan

Please include your current Strategic Plan

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

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* 10. For the Silver, Gold and Platinum tiers, please attach your Board Resolution supporting the agency pursuit of Excellence.

PDF, DOC, DOCX, PNG, JPG, JPEG file types only.

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* 11. IRS Form 990

For those enrolling in Silver, Gold, and Platinum levels, please include your most recent IRS Form 990. The 990 is used to verify tier pricing. Public CAAs should upload official documentation of budget size to verify tier pricing.

PDF, DOC, DOCX, PNG, JPG, JPEG file types only.

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* 12. Payment Options - Please select your preferred billing and payment method below.

Receive an invoice by email followed by a phone call from an NCAP staff member to facilitate processing of an online credit card payment.

Receive an invoice by an email to the primary contact for payment by check through the mail.

Please provide phone number, if payment by phone is selected.

Congratulations on starting your excellence journey! We will follow up with you to confirm receipt of your materials soon.

If you have any questions in the meantime, please contact us:

Excellence@CommunityActionPartnership.com

Please click "submit" to complete this form.