Community Service Assignment Form
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Community Service Assignment Form
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1. Name of participant _______________________ 2. S.S. # ______________________
3. Grantee _______________________________________________________________
Host Agency Information
4. Name of host agency ____________________________________________________
5. Host agency mailing address
_____________________________________________________________________
a.
Number and street, suite number; or PO Box
_____________________________________________________________________
b.
City
_____________________________________________________________________
c.
State
_____________________________________________________________________
d.
Zip code
6. FEIN___________________________________
7. Host agency type
a. Private not-for profit
b. Government
Contact Information
8. Host agency site name and location_________________________________________
________________________________________________________________________
9. Name of contact person _________________________________________________
10. Contact person’s mailing address if different from number 5
_____________________________________________________________________
a.
Number and street, suite number; or PO Box
_____________________________________________________________________
b.
City
_____________________________________________________________________
c.
State
_____________________________________________________________________
d.
Zip code
11. Contact person’s title ___________________________________________________
12. Contact person’s phone number __________________________________________
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Parent category: Business