Non Profit Off Campus Work study Eligibility Questionnaire This questionnaire is for Wisconsin non-profit organizations to determine their eligibility as a prospective UW-Madison Federal Work-Study partner. Complete Name of Organization* Phone Number of Organization*Contact Name (please list the first and last name of the person you want us to reach out to about work study eligibility)* Email Address (please list the email you want us to reach out to about work study eligibility)* Address of Organization* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name of Organization Director* First Last Organization Director Email Address* Address of Organization Director (if different from above) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code My organization is a part of the SuccessWorks Community Impact Internship Program?* Yes No My organization is a registered and certified 501c3 non profit?* Yes No Through what sources is this organization funded? (please indicate by percent each source is funding your org)*What is the purpose and general function of this organization?*For what types of jobs do you intend to hire Work-Study Program students?*What groups, populations and/or agencies does your organization serve?*What need(s) in the community does your organization serve?*What eligibility criteria do you use in selecting your clients or target groups?*Are there any membership requirements? (Please be specific)*Is this position being created as a result of response to a community need, a newly created position, or some other reason?*Please provide any additional information, which would aid us in determining your eligibility to hire Work-Study students.*Acknowledgment* I certify the information provided above is accurate to the best of my knowledge.