InterAction Associate Member Application Form
1. ORGANIZATION NAME:
NAME OF THE CEO/ DIRECTOR:
EMAIL ADDRESS:
TELEPHONE:
2. CONTACT PERSON FOR APPLICATION PROCESS:
EMAIL ADDRESS:
TELEPHONE:
3. ORGANIZATION ADDRESS:
4. TELEPHONE:
5. FAX:
6. GENERAL EMAIL ADDRESS:
7. WEBSITE:
8. YEAR FOUNDED:
9. OFFICIAL REGISTRATION:
If headquartered in the US indicate state in which incorporated:
Outside the U.S. please indicate country and location of registration:
10. STATEMENT OF ORGANIZATIONAL PURPOSE:
11. BRIEFLY DESCRIBE YOURORGANIZATIONAL STRUCTURE AND PROGRAMS.
INCLUDE A LISTING OF THE LOCATION OF FIELD OFFICES OR REGIONAL
OFFICES WORLDWIDE.
12. WHY DOES YOUR ORGANIZATION WISH TO JOIN INTERACTION AND HOW
WOULD YOU AND YOUR STAFF EXPECT TO PARTICIPATE?
13. DESCRIBE YOUR GOVERNANCE STRUCTURE:
a) INDEPENDENCE OF YOUR HIGHEST GOVERNING BODY
b) SIZE OF YOUR HIGHEST GOVERNING BODY AND ITS COMMITTEES
c) FREQUENCY OF MEETINGS
d) DO ANY OF YOUR GOVERNING BODY MEMBERS RECEIVE
COMPENSATION FOR HIS/HER WORK ON THE BOARD?
e) DOES THE GOVERNING BODY APPROVE YOUR BUDGET?
14. NUMBER OF FULL-TIME, SALARIED STAFF IN THE COUNTRY OF
REGISTRATION; IN THE FIELD INVOLVED IN PROGRAMS.
15. DOES YOUR ORGANIZATION HAVE AN EMPLOYMENT POLICY REGARDING
STAFF GENDER, DIVERSITY AND MINORITY REPRESENTATION?
Number of senior staff positions held by women:
Titles:
Number of senior staff positions held by minorities: Titles:
Number of staff positions held by people with disabilities:
Titles:
16. LIST THE NAME AND TITLES OF YOUR HIGHEST GOVERNING BODY’s
CHAIRPERSON AND ITS MEMBERS.
17. DOES YOUR GOVERNING BODY HAVE A POLICY REGARDING BOARD
GENDER, DIVERSITY AND MINORITY REPRESENTATION?
(With minority we mean a racial, religious, political, national, or other group that has a
small representation relative to the larger group of which it is part).
Number of board positions held by women:
Number of board positions held by minorities:
18. DOES YOUR ORGANIZATION HAVE THE FOLLOWING WRITTEN POLICIES?
a) Conflict of interest policy
b) Whistleblower policy
c) Document retention and destruction policy
19. PLEASE INDICATE THE APPROXIMATE AMOUNT OF THE FOLLOWING
FUNDING SOURCES AS A PERCENTAGE OF YOUR TOTAL ANNUAL INCOME:
US Government Grants/Contracts: %
Other Government Grants/Contracts: %
Contributions: %
Explain the source:
(E.g. individual/public, corporate giving)
Commodities in-kind: %
Others: %
Explain the source:
Required application materials:
 Completed Application
 Organizational Documents, such as:
 By-Laws or other governance document
 If U.S. based: Articles of Incorporation and IRS Letter of Tax-Exempt Status
 If non U.S. based: Certificate of registration as a non-profit entity
 Most Recent Annual Report
 Associate Member PVO Standards Review Form
 Most Recent Financial Report
 Current Year's Budget, as Approved by the highest governing body
 3 Letters of Recommendation from Current InterAction Members
2014 Application submission deadlines:
April 28, 2014
July 28, 2014
October 20, 2014
Dues Calculation
InterAction's membership dues are calculated at .15% of assessable expenses with minimum dues of
$2,000 and maximum dues of $48,000.
An example of calculated dues:
The organization HelpUS has annual expenses of $10,000,000, but has in kind expenses of $450,000 and
a domestic program with expenses of $975,000. The InterAction dues fee would be calculated as
follows:
$10,000,000
- 975,000
Annual Expenses
Domestic Program Expenses
[not applicable for international applicants]
- 450,000
In-kind Expenses
$ 8,575,000
x .0015
$12,863
Assessable Expenses
Annual Dues
Therefore, HelpUS would pay annual dues of $12,863 for membership in InterAction.
In order for your potential dues to be calculated, please visit the following link (start by creating a
login) and complete the form so that the Membership team can estimate your dues.
http://www.interaction.org/annual-financial-information-collection