Application for Design Services
Agency or Organization Name:
Address Line 1:
Address Line 2:
City: State: Zip:
Brief description of services your agency provides:
Description of project:
Has your board approved this project? Yes No
Board Contact Name:
Board Phone Number:
Please attach a PDF copy of your agency's 501c3 exemption Letter:
Is your agency insured? Yes No
Type of Coverage:
Please attach a PDF copy of your Insurance Certificate coverage:
Can your agency provide the following for this project?
Funding: Yes No
If yes, how much?
Trucking: Yes No
Trucking Contact Name:
Trucking Phone Number:
Volunteers? (Can include board members, staff and clients) Yes No
Please describe how your agency would benefit from PBD services:
When do you want the project to begin?
When do you need to be finished?
Please describe any unusual conditions regarding timing (e.g. leasing conditions, joint occupancy, funding, other):
List of furnishings requested: