InterAction Membership Application For both member and associate member applicants, your organization must complete the following application and submit the required supplemental materials to Kellie Peake at [email protected]. The supplemental materials include: □ A copy of your organization’s by-laws (or similar statement for an associate member) □ Articles of Incorporation (or similar statement for an associate member) □ IRS Letter of Tax Exempt Status (or similar statement for an associate member) □ Most recent Annual Report □ Most current Audited Financial Statement □ Most current 990 (or similar statement for an associate member) □ Three letters of recommendation from the CEO or President of an NGO, PVO or CSO, on their letterhead, InterAction members preferred □ A signed copy of InterAction’s Standards Review Form (does not apply to organizations applying as an associate member) For questions about the InterAction application process, contact Carolyn Aeby at [email protected]

Last Update: October 2017

Section 1: Basic organization and contact information Please check if you are applying as an InterAction Member or InterAction Associate Member □ □ □ □ □

InterAction Member – 501c3 registered in the U.S. InterAction Associate Member – International NGO InterAction Associate Member – University department InterAction Associate Member – Think Tank InterAction Associate Member – Other

Organization Name: Organization HQ Address: Organization HQ Telephone: Organization website: Year Founded: Incorporated in the state of: Statement of organizational purpose: This may include your mission, vision, and/or strategic goals. Briefly describe your organizations programs: Include a listing of the location of field offices or regional offices worldwide Name of CEO: CEO Title: CEO Email Address: CEO Telephone: Contact Person: The contact person is the individual the InterAction Membership Team will communicate with regarding all application materials. Contact Person Title: Contact Person Email Address: Contact Person Telephone:

Last Update: October 2017

Section 2: Interest in joining InterAction Why does your organization wish to join InterAction? Please keep your response between 300-500 words. How would your staff expect to participate? Check all that apply. For more information about how InterAction works with our members, visit our website www.interaction.org Working Groups □ Communications Directors Working Group □ Disability Working Group □ Disaster Risk Reduction (DRR) Working Group □ Evaluation and Program Effectiveness (EPE) Working Group □ Food Security and Agriculture (FS/Ag) Working Group □ Gender Based Violence (GBV) Working Group □ Global Health (GH) Working Group □ International Humanitarian Law (IHL) Working Group

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Shared Interest Groups □ Climate, Environment and Development □ Crisis/sudden onset (i.e. Hurricane Matthew) □ Gifts-in-Kind □ Great Lakes □ Health-related emergencies (Ebola) □ Horn of Africa Initiatives □ G7/G20 Advocacy Alliance (U.S.) □ Results-Based Protection □ Narrative Project □ NGO Aid Map □ Democracy, Rights and Governance

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Sustainable Development Goals (SDG) Working Group Private Sector Working Group Protection Working Group Public Policy Committee (PPC) Refugee Policy Working Group Security Advisory Group (SAG) Working Group Shelter and Settlements Working Group Social Media Working Group Syria/Iraq Working Group Water, Sanitation and Hygiene (WASH) Working Group West Bank/Gaza Working Group

Lake Chad Basin Pakistan Prevention of Sexual Exploitation and Abuse (PSEA) Sudan/South Sudan Yemen

The Rockefeller Foundation’s Bellagio Center The Together Project NGO Futures Initiative for Open Ag Funding Young Professionals Network

Pledges □ NGO Global Food Security Pledge □ Humanitarian Action Pledge Last Update: October 2017

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Global Nutrition Pledge

Partnerships □ Basic Education Coalition Events □ □ □ □ □

Forum (attend) Forum (host a breakout session) Forum (sponsor) CEO Retreat Regional member meetings

How many staff members do you expect will participate in InterAction activities and who are they? Please provide contact information and/or anticipated roles or departments that will participate in InterAction activities

Last Update: October 2017

Section 3: Governance Standards and Employee Policies Describe your governance structure in terms of the following. If you are applying as an associate member and do not have a board or governing body, please provide information on your governance and accountability structure. □ Independence of your board: □ Size of board and executive committee: □ Frequency of meetings: □ Does any member receive compensation for his/her work on the board?: □ Does the board approve your budget?:

Does your organization have the following written policies? □ Conflict of interest policy □ Whistleblower policy □ Document retention and destruction policy

Last Update: October 2017

Section 4: Partnerships Do you work with partner organizations overseas? Please list three NGOS or CSOs with which your organization has worked in the last two years. Please list the three organizations who are sending in a letter of recommendation on your behalf:

Last Update: October 2017

Section 5: Finances Does your organization have any program(s) that focuses on the United States Domestic only; Domestic expense is defined as domestic (U.S.) activities that have no relationship to international activities, programs, or issues.)?: If so, what are the total expenses associated with your domestic work?: Does your organization receive any gifts in kind? If so, what is the total monetary value of the gifts-inkind expensed for the year as represented on your financial statements?:

Last Update: October 2017