WRJSL Placement Agency Approval Form

Organization Name:

Your Name (first and last):

Title:

Address:

City:

State:

Zip/Postal Code:

County: Select ... Ashtabula Geauga Lake

Email:

Phone Number:

Please include your Mission and/or Vision Statement:

Are you a 501(c)3? Select ... Yes No

Please upload the 501(c)3 Determination Letter:

Date:

By checking here, I affirm that all details and representations made in this application are true and correct to the best of my knowledge.

I affirm.

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