New Partner Contact FORM

Please complete the following information to help us draft your grant agreement, register your team for our portal, and set up your fund with The Change Reaction.

Marketing Coordinator Full Name*

Marketing Coordinator Email Address*

Name of Organization*

Address, City and Zip Code*

Grant Agreement Signatory/Full Name and Title*

Grant Agreement Signatory/Email Address*

Name of Executive Director/CEO*

Executive Director/CEO Email Address*

Executive Director/CEO Mailing Address*

Additional Contacts

If you have additional contacts at your organization that you would like to be connected with this partnership, please share below.

Name and Title of contact

Contact Email Address

Contacts needing Portal Access

Please include full name and email address for anyone in your organization that will need access to our portal to submit requests for consideration.

Contact 1 - Full Name and Title

Contact 1 - Email Address

Is Contact 1 Going to be a Head Change Agent?

YES

Contact 2 - Full Name and Title

Contact 2 - Email Address

Is Contact 2 Going to be a Head Change Agent?

YES

Contact 3 - Full Name and Title

Contact 3 - Email Address

Is Contact 3 Going to be a Head Change Agent?

YES

If you have additional contacts you would like to give access to please include their names, titles and email address in this field below.

Upload IRS Determination Letter

Upload File

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Upload Logo

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New Partner Contact FORM

Additional Contacts

Contacts needing Portal Access

Upload IRS Determination Letter

Upload w9

Upload Logo

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