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Business Organization Information Form

This form must be completed by all CIPE applicants and submitted with project proposals. This information will be used in evaluating proposals and will become a part of a clearinghouse of information that CIPE is collecting on business organizations throughout the world. As part of this clearinghouse, information from this form will be made available to researchers. If any of the information provided is not for publication, please so indicate below.

The following section (s) are not for publication:

Name of Organization:

Street Address:

Mailing Address:

Postal Code:

City:

Country:

Phone No.:

Telex No.:

Fax:

E-mail Address:

1. General Information

Please attach a copy of your most recent annual report.

Type of Organization:

Statement of Purpose:

2. Personnel

Please attach a list of personnel and position descriptions.

Chairman (chief elected official):

Executive Director (chief paid staff executive)

Number of Full-time Employees:

Part-time:

Consultants:

3. Membership

Total:

Organization / Corporation:

Individuals:

Numerical growth in last 3 years:

Expected numerical growth in next 3 years:

Percentage of membership by size of business (No. of employees):

0-10:		%
10-25:		%
25-30:		%
50+ :

4. Financial Information

Please attach a copy of your most recent financial report.

Current year annual budget: Local currency:

U.S.$:

Exchange Rate:

Previous year annual budget: Local currency:

U.S.$:

Exchange Rate:

Sources of support (by percent of total of current year):

* Member Contributions:

* Seminars/ Conferences:

* Publications:

* Services:

* Government:

* Other (please specify):

* Revenue from local sources:

* Revenue from foreign sources:

5. Organizational Activities

(Describe type of activities & purpose):

Member Services:

Information/ Consulting Services:

Publications:

Seminars/ Conferences:

Community:

Training or Education programs:

Other (please specify):

6. Affiliations

Local/ Regional Organizations:

Foreign or International Organizations:

In addition to your annual report, audited financial statements and staff list, please attach any other materials, brochures, research reports, seminar or conference announcements and programs, and other publications that will further describe your organization.