7#_3]+ $t$P&3nptxz~OFFICE ONLY: Application #: ___________________ Application Form: Cultural Leadership Partners Program IOWA DEPARTMENT OF CULTURAL AFFAIRS Deadline for this application and all attachments is no later than 4:30 pm, July 2, 2007. This is not a postmark deadline. All applicants must show that they have met ALL of the eligibility requirements of the Cultural Leadership Partners Program for the three previous completed operating years prior to the application deadline. Mail or hand-deliver this form and all attachments in one package to: Cultural Leadership Partners, Grants Office, Department of Cultural Affairs, Cultural Leadership Partners Program, Administrative Office, 3rd Floor West, 600 E Locust, Des Moines, IA 50319-0290. Questions? Contact Bruce Williams at [bruce.williams@iowa.gov], 515-281-4006. Email is our preferred method of communication. ASSURRANCES. The Director (Person in Charge) listed below is legally authorized by the applicant to submit this application. By submitting this application, the Director certifies that the information contained in it, including all attachments, are true and correct to the best of the Directors knowledge. Section 1: INFORMATION ABOUT THE APPLICANTLegal Name of Applicant AKA Name Address City: , State: Zip: - Website Legal Status (check all that apply) -IA NONPROFIT ORGANIZATION: Iowa Corporation Number . Include a copy of your articles of incorporation and by-laws with your support materials. Identify in Section 18. -FEDERAL TAX EXEMPT ORGANIZATION: 501( c) Attach your federal tax-exempt notification letter. -MUNICIPAL GOVERNMENT: Arts or cultural organization that is part of a department or division of municipal government. Include in your support materials a copy of the legal document that verifies you are part of a municipal government. Identify in Section 18. Employer Federal ID Number Type of SupportGeneral Operating SupportApplicant Contacts (emails required) Director (Person in Charge): Other Contact:  Name: Title: Email: Name: Title: Email: Operating Year You will be asked in the application to provide information regarding several operating years. Specify the dates as: dd/mm/yyyy (least recent) - Previous 3 Operating Years (most recent) Current YearYear 3: Beg: End: Year 2: Beg: End: Year 1: Beg: End: Beg: End: Operating Budgets (expenses): Obtain figures from IRS 990 tax form-line 17. If you do not submit Tax Form 990 to the IRS, please submit similar figures. Refer to the IRS 990 instructions booklet for guidance.Year 3: $ .00 (actual)Year 2: $ .00 (actual)Year 1: $ .00 (actual)Current Year: $ .00 (estimate) Type of Organization. Eligible organizations are: - Arts organizations: primary mission and purpose must be the arts; it must operate as an arts organization. - Cultural organizations: primary mission and purpose must be cultural; it must operate as a botanical center, museum, zoo, or a center for the performing arts. What is the PRIMARY type of art or cultural organization that best describes you? ARTS ORGANIZATION: Single discipline Check only one of the following: -Crafts -Dance -Design arts -Interdisciplinary -Literature -Media art -Music -Opera, music theatre -Photography -Theatre -Traditional folk arts (does not include folk-inspired, folk-revival or recreation) -Visual arts (includes drawing, painting, printmaking, book arts, sculpture; does not include graphic design) -Other: ARTS ORGANIZATION: Multi-discipline Check all that apply: -Crafts -Dance -Design arts -Interdisciplinary -Literature -Media art -Music -Opera, music theatre -Photography -Theatre -Traditional folk arts (does not include folk-inspired, folk-revival or recreation) -Visual arts (includes drawing, painting, printmaking, book arts, sculpture; does not include graphic design) -Other: CULTURAL ORGANIZATION: -Botanical center -Center for the performing arts -Museum -Zoo -Other:  What is your DUNS number? Dont have one? In order to more easily track arts and culture economic impact data for Iowa, all applicants (who have not already done so) are to register with D&B to receive a DUNS number (Data Universal Numbering System). DUNS numbers are also required by the National Endowment for the Arts and other Federal grant programs. There is no fee for registering for a DUNS number. Organizations may register by phone or online. It only takes a day to get a DUNS number by phone (you may be on hold for a little while). Note that an authorizing official of the organization should request a DUNS number. For details call D&B's special toll-free number for government grant applicants: 1-866-705-5711 or visit http://fedgov.dnb.com/webform to register on-line. (Choose the "DUNS number only" option. You will need a valid e-mail address to complete the registration.) Are you part of another organization, institution or governmental entity? Yes- No- If you checked yes, list the name of the entity and describe your relationship with it. Are there any specific goals in your strategic plan regarding the legal status of your organization? Yes- No- If you checked yes, summarize the goals. Section 2: OPERATING BUDGET Organizations must maintain an operating expense budget, exclusive of DCA/IAC general operating support, of no less than $150,000. Attach copies of your federal IRS 990 tax reports and annual reports for the last three years. Identify in Section 18. Organizations that are departments or divisions of municipal governments must provide similar budget information What is your operating budget (expenses) for your current operating year and three previous operating years? Obtain figures from page 1: Year 3: $ .00 (actual)Year 2: $ .00 (actual)Year 1: $ .00 (actual)Current Year: $ .00 (estimate) On average, what percent of your annual operating budget is obtained from the following? The total does not need to equal your total income. % from Contributed income % from Earned income % from Grants % from Support Groups % from an Endowment. When was it established and how large is it? Do you manage it or is it managed by other organization? Do you receive any funding from the city or county? Yes- No- If you checked yes, summarize on average how much you receive each year and what it supports (e.g., general operating support, specific projects or programs, etc.). What are the major budget challenges you see facing your organization in the next three to five years? Are there any specific goals in your strategic plan regarding your operating budget? Yes- No- If you checked yes, summarize the goals. Section 3: YEAR-ROUND OPERATION Organizations must operate year-round on a continuous basis for 12 months of the year. The organizations facilities, programs and services must be available to Iowans at least 1040 hours per year. Do you operate year-round? Yes- No- If you checked yes, how many hours do you operate each year? Summarize when you are open to the public and when your programs are accessible to Iowans (e.g., days/months open, hours of operation, days closed, etc.). Are there any specific goals in your strategic plan regarding your operating year? Yes- No- If you checked yes, summarize the goals. Section 4: AMERICANS WITH DISABILITIES ACT Organizations funded through this program are expected to make every attempt to have their facilities and programs accessible to people with disabilities. Accessibility involves both location (the facility) and the content (the activity or product) of the program. In general, how would you rate the level of accessibility of your facilities and programs?  AccessibleNOT ACCESSIBLE Exemplary The Best ImpressiveAbove Average Better than Good More than AdequateAverage Adequate O.K.Less Than Average Not Adequate Not O.K.16151413121110987654321Facilities - includes facilities you own, rent or utilizePrograms Do you have a policy or plan regarding accessibility? Yes- No- If you checked yes, summarize it or include a copy of it with your support materials. Identify in Section 18. Summarize what you have you done within the past three years to make your organizations facilities and programs accessible to people with a disability. Are there any specific goals in your strategic plan to make your facilities and programs accessible to people with a disability? Yes- No- If you checked yes, summarize the goals. Section 5: MISSION & VISION What is your mission statement and/or vision statement? Indicate when they were last updated. If necessary, further explain these statements. Are there any specific goals in your strategic plan regarding the mission statement and/or vision statement? Yes- No- If you checked yes, summarize the goals. Section 6: HISTORY Include a summary of the history of your organization with your support materials. Identify in Section 18. Section 7: STRATEGIC PLAN Include a copy of your strategic plan with your support materials. Identify in Section 18. Summarize the process you used to evaluate your previous strategic plan and the process you used to develop your current strategic plan. Identify the constituency groups involved and a timeline. Summarize the key goals of your strategic plan and how you will measure their success. Summarize any major changes from the previous plan. What are the major challenges you see facing your organization regarding your strategic plan in the next three to five years? Are there any specific goals in your strategic plan regarding your strategic plan? Yes- No- If you checked yes, summarize the goals. Section 8: CULTURAL LEADERSHIP & ADVOCACY Cultural leadership and advocacy. Describe your organizations role in advancing the arts and culture in your community and in Iowa. Partnerships. Summarize significant or unique partnerships you have developed over the past three years with other leaders, organizations, businesses, and individuals to advance arts and culture in your community and in Iowa. Are there any major challenges you see facing you regarding cultural leadership and advocacy in the next three to five years? Are there any specific goals in your strategic plan regarding cultural leadership and advocacy? Yes- No- If you checked yes, summarize the goals. Section 9: BOARD OF DIRECTORS Include a lists of your current Board your support materials. Identify in Section 18. Provide the following information in the order it is listed: BOARD OFFICERS: Name, position on board. City/state. Number of years on the board. Month/year current term ends. Number of terms served. OTHER BOARD MEMBERS: Name, position on board. City/state . Number of years on the board. Month/year current term ends. Number of terms served. Makeup of the Board Previous Operating Year 3Previous Operating Year 2Previous Operating Year 1Current Operating YearTotal number of Board members    How many are between the age of 18 and 35? How many live in your community? How many live outside Iowa? How many are new this year?  General Board Responsibilities. Describe the responsibilities of the board. Board Oversight Responsibilities. Does your Board have any oversight responsibilities of your organization? (e.g., oversight of contracts, finances, personnel, etc.) Yes- No- If you checked yes, summarize the primary oversight responsibilities. Board Recruitment. Describe the process you use to identify and recruit new Board members. Board Training. Is there an orientation or training process in place for new Board members? Yes- No- If you checked yes, summarize them. Describe the age, gender and ethnic/racial makeup of your current Board. How many Board meetings do you hold each year? Do not include committee/taskforce meetings. On average, what percent of your Board regularly attend Board meetings? Who serves as the chairperson of the Board? (e.g., Board president, chief operating officer, executive director) Who sets the agenda for Board meetings? (e.g., Board chair, executive director) Does the Board receive information in advance of the meeting? Yes- No- If you checked yes, summarize how they typically receive information. (e.g., by mail, by email, available on website) Do Board members have term limits? Yes- No- If you checked yes, summarize how long they are and the number of terms they can serve. When did the Board last review the Executive Director's performance? Does the organization have a conflict of interest policy in place for the Board? Yes- No- If you checked yes, what is it? Does the organization provide (liability) insurance for the Director and/or Board? Yes- No- Do you have job descriptions or set of expectations in place for Board members? Yes- No- If you checked yes, summarize them. When did the Board last conduct a self-assessment or review? When did the Board last develop and/or approve a strategic plan and did the full Board participate in the development of the plan? When did the Board last review and approve the agency mission and/or vision statement? On average, what percent of the Board regularly attends or participates in programs and activities of the organization? % Board Committees. How many Board committees are there? Identify each committee and describe its function or purpose, and goals or set of expectations. Changes to the Board. Describe any major changes that have occurred during the previous three years regarding your boards makeup, number of members, number of times they meet, responsibilities of board members, reorganization of the board, etc. Are there any major challenges you see facing Board governance and management in the next three to five years? Are there any specific goals in your strategic plan regarding your Board and Board committees? Yes- No- If you checked yes, summarize the goals. Section 10: BOARD FUNDRAISING Are Board members expected to personally contribute financially to your organization? Yes- No- If you checked yes, what are they typically expected to do? On average, what percent of your income is raised by the Board? Are Board members responsible for raising funds for your organization? Yes- No- If you checked yes, what are they typically expected to do? On average, what percent of your income is raised by the Board? Are there any major challenges you see facing you regarding fundraising by your board in the next three to five years? Are there any specific goals in your strategic plan regarding Board fundraising? Yes- No- If you checked yes, summarize the goals. Section 11: SUPPORT GROUPS Do you have support groups such as a foundation, guild, club or chapter that support your organization? Yes- No- If you checked yes, describe each support group and summarize how they support your organization. Do the above support groups raise funds for your organization? Yes- No- If you checked yes, describe how much do they typically raise each year and if they decide how the funds are to be used. Are there any major challenges you see facing you regarding your support groups in the next three to five years? Are there any specific goals in your strategic plan regarding support groups? Yes- No- If you checked yes, summarize the goals. Section 12: CONSTITUENTS SERVED Primary Service Area. Mark in black ink an X where you are located. Highlight with a Yellow marker the PRIMARY Iowa counties you serve in a meaningful way. For example, identify the county in which your organization resides. You could also identify counties in which a substantial number of people you serve reside (e.g., neighboring counties). If you have touring or outreach programs, identify the counties they occurred in.  Describe who your primary constituents are. Describe the age, ethnic, racial and gender makeup of your constituents. Total number of constituents served: Previous Operating Year 3Previous Operating Year 2Previous Operating Year 1Current Operating YearA: Total number of constituents served:    B. What percent are Iowans? % % % % What methodology do you use to determine the total number of constituents and how many are Iowans? Are there any major challenges you see facing you regarding the constituents you serve in the next three to five years? Are there any specific goals in your strategic plan regarding your service area and the constituents you serve? Yes- No- If you checked yes, summarize the goals. Section 13: CORE PROGRAMS List your core programs. If you conduct several programs or activities under one name, list it as one program (e.g., Exhibitions, Concert Series, Education Programs, or Technical Assistance). List them in order of priority or importance to your organization. Description of Core Programs. Include a summary of the core programs identified above with your support materials. Identify in Section 18. Provide the following information about each program. Name of Program a) Description and purpose of the program and how it relates to your mission and purpose. Specify if it is a new program or an education program. b) Describe any core constituencies it primary serves or benefits c) Describe any unique qualities of the program. d) Describe major challenges you see in the next three to five years. d) Employee or person in charge of the program. Include name and title. Are there any major challenges you see facing you regarding your core programs in the next three to five years? Are there any specific goals in your strategic plan regarding your core programs? Yes- No- If you checked yes, summarize the goals. Section 14: EMPLOYEES Include a list of your current employees with your support materials. Identify in Section 18. Provide the following information in the order it is listed: MANAGEMENT EMPLOYEES Name, title and/or position, email, phone. Specify full or part-time; permanent or temporary/contracted OTHER EMPLOYEES Name, title and/or position, email, phone. Specify full or part-time; permanent or temporary/contracted Include an employee chart that visually illustrates the organizational structure of your employees with your support materials. Identify in Section 18. Director. Identify the paid full-time professional employee who is employed year round and works at least 1,560 hours per year (e.g., 30 hours per week x 52 weeks), and is responsible for managing the organization. Are any considered city employees? Yes- No- If you checked yes, how many are city employees? Changes to employees and/or positions. Describe any recent major changes to positions, reorganization of employees, job responsibilities, number of hours, etc. Professional development. Describe training or educational opportunities provided to employees. Indicate if they are provided the opportunity to network with their peers on the local, state, regional or national level. Strategic planning. Describe how your employees are involved in developing, updating and evaluating of your strategic plan and core programs and services. Is there an orientation or training process in place for new and/or current employees? Yes- No- If you checked yes, summarize what you do. Do you have a conflict of interest and/or ethics policy in place for employees? Yes- No- If you checked yes, what is it? Does the organization provide health insurance or retirement benefits for employees? Yes- No- Do you have job descriptions and annual performance measures for employees? Yes- No- How often are performance evaluations conducted for your employees? Are there any major challenges you see facing you regarding your employees in the next three to five years? Are there any specific goals in your strategic plan regarding your employees? Yes- No- If you checked yes, summarize the goals. Section 15: VOLUNTEERS Number of Volunteers and Hours. Obtain from Section 16D. Total number: Total estimated hours volunteered: Over the past three years, the total number of volunteers has: -held steady; -increased; -decreased What do your volunteers typically do for you? Do you have a volunteer coordinator? Yes- No- How do you retain and recruit volunteers? Are there any major challenges you see facing you regarding your volunteers in the next three to five years? Are there any specific goals in your strategic plan regarding volunteers? Yes- No- If you checked yes, summarize the goals. Section 16: BOARD / EMPLOYEE STATISTICS 16A) Total number of Board members How many were newly appointed this year?  How many will end their term after this year? How many are between the ages of 18 and 35?  16B) Total number of paid employees (*Full time is considered 1560 hours or more per year) How many are full-time* positions:  How many are part-time positions: How many are full-time* contracted positions: How many are part-time contracted positions: 16C) Number of types of positions of paid employees listed in 16B. Because employees often assume several responsibilities, the total number listed below does not need to equal the total in section 16B.Employees you consider senior management Artistic (e.g., artistic directors, conductors, curators, composers, choreographers, designers, actors, artists; do not include education) Communications, marketing and promotion Development, fundraising Business/finance office Community relations and membership Education (e.g., education directors, artist-teachers/instructors, etc.) Security Facility maintenance  Library Information technology (does not include communications, marketing and promotion) Technical and production: (e.g., technical directors, lighting, stage hands/technicians, exhibit preparers and installers, costumes, etc.) Others not listed above: types: ) 16D) Total number of volunteers Estimated number of hours volunteered:  Section 17: SAMPLES OF PROGRAMS, CATALOGUES, NEWSLETTERS, ETC. 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