Social Venture Partners Cincinnati
2016-2017 Joint Fast Pitch and Investee Selection Application Form
ORGANIZATION INFORMATION
Applicant Organization (Legal Name):
DBA/Previous Name (if changed):
Street Address:
City:
Website:
State:
Zip:
Phone:
Fax:
Executive Director/CEO:
Email:
Phone:
Email:
Phone:
Name of Person Completing the Application (if different):
TAX STATUS
Is your organization a 501(c)(3) charity?
Yes
No
Legal Name, per IRS letter:
RESOURCES
# Employees - Full-Time:
EIN #:
Part-Time:
FTE:
# Volunteers -
Size of Endowment: $
Current operating budget: $
Percent of Budget:
Audited:
Federal Funds _________
Local Funders __________
Yes
No Year: ________
Earned Revenue __________
Other(Specify) _________
Program budget, if applying for specific program within your organization: $
LIST OF MAJOR FUNDERS
Major Funders:
AFFILIATIONS AND/OR ACCREDITATION BODY:
United Way _______ ArtsWave_______
Better Bus. Bureau _______
Strive Partnership _______
Community Shares _______
Other (Specify) ___________________________________________________
Former Fast Pitch Finalist/Semi-Finalist _____ Year _____
Former SVP Investee Finalist _____ Year _____
Chapter of Regional or National Organization ___________________________________________________________
If yes, explain funding arrangement:
Signatures:
Executive Director: _________________________________
Date: _________________________________
Board President: ___________________________________
Date: _________________________________
2016-2017 Application Form – Social Venture Partners Cincinnati
SVP Application Questionnaire - SECTION 1
(Both Fast Pitch and Investee Applicants)
Describe your organization in one sentence:
Briefly state your organization/venture’s Mission and Goals:
What is the Problem or Need that your organization is addressing?
Please include a definition of the population served, the geographic area served and number of individuals served
annually. Consider impact of the social issue you address as well as the way that it affects people, communities, etc.
How is your approach to this social issue innovative?
What are you doing that is unique or different? Innovation can include applying a proven solution to a new problem,
introducing a program to a new community, forging new partnerships/coalitions, etc.
What results have you seen or do you expect from your social innovation?
Share measures and metrics you are using to monitor impact. Describe quantitative indications/results if possible.
Are you currently operating a social enterprise? If “Yes”, have you generated any revenue? If “No”, have you done
any market research yielding verifiable information about the size of your market and your competition?
Flywheel Social Enterprise Hub will be awarding a “Social Enterprise Award" at Fast Pitch. A social enterprise is a business
that earns revenue and directly addresses a social need either through products and services it sells or through people
it employs.
Primary contact person should we have questions on the application. Include phone and email.
2016-2017 Application Form – Social Venture Partners Cincinnati
Fast Pitch Legal Release:
TYPE YOUR FIRST & LAST NAME below, signifying that you have read and agree to these terms as it relates to the Fast
Pitch Program: Whereas you, the Fast Pitch applicant, hereafter called "Applicant" desires to have the privilege of
participation in the Social Venture Partners Fast Pitch Program. Therefore, it is agreed as follows: That in consideration of
Social Venture Partners, Cincinnati, Ohio, allowing, subject to its rules and regulations, the Applicant (linked to this form)
on behalf of themselves and guardian or parent, if under 18, do hereby voluntarily assume all risks of accident or damage
to the person or property of the Applicant participating in said program and do hereby release and discharge Social
Venture Partners, and its agents, from every claim, liability or demand of any kind however caused for or on account of
the personal injury or damage of any kind sustained by said Applicant while participating in said project. The Applicant
further promises to indemnify and forever save harmless Social Venture Partners or its agents from every claim, liability
or demand of any kind however caused, for or on account of the personal injury or damage of any kind sustained by said
Applicant, if enrolled in said project. In the event of an accident, the Applicant’s medical coverage should respond.
Additionally if a claim is made against the Applicant of a personal liability nature, personal homeowners and/or renters
insurance should respond.
FIRST NAME
LAST NAME
We are applying for:
Fast Pitch 2017 __________ 2017 SVP Investee __________ Both __________
If applying to be 2017 SVP Investee or Both, please proceed to the next section.
If applying just for Fast Pitch 2017, thank you for your interest and application. Please submit your completed
application to [email protected] by Midnight on August 15th.
Questions about your application?
Contact Lauren Merten, SVP Executive Director
[email protected]
(513) 458-6715
2016-2017 Application Form – Social Venture Partners Cincinnati
SVP Application Questionnaire - SECTION 2
Investee Applicants Only
I.
Organizational Overview – Additional Information
Tenure of ED in this Position
Describe your succession plan
for key management and
employees
Year Established
Organization’s History
(3-5 sentences)
Who does your financial
accounting and what are his/her
qualifications?
II. Detail on Organization Objectives and Potential for Impact
What are the top 3 challenges
currently facing your
organization?
What is innovative about
your organization and your
approach to serving the
Greater Cincinnati
community?
How do you measure
effectiveness and impact of
your programs? What are
your key metrics and/or
performance indicators?
Is your organization scalable?
How would additional
resources be used?
2016-2017 Application Form – Social Venture Partners Cincinnati
III. Governance
Number of Board Members
Number of board meetings
annually
Average attendance of
board members at board
meetings in the past year
Percentage of board members
who have personally donated to
the organization during the last
fiscal year
Average amount board
members contribute annually
Is board member financial
contribution required or
voluntary?
Do the board and committees
of the board have job
descriptions?
Does the board have a conflict
of interest policy?
Do you have D&O insurance?
Are there defined terms for
board membership?
How long have current
members served?
Name the active committees of
the Board and the key
objectives of each.
Do you have a succession plan
for leadership and key
employees? If so, please
describe.
IV. Strategic Planning
Do you have a current Strategic
Plan? If YES, please include it as
an attachment.
If YES:
How was your Strategic
Plan developed? When
was it developed? Were
current management
and/or Board members
involved?
2016-2017 Application Form – Social Venture Partners Cincinnati
In January of 2020 what will the
press release for your
organization or program/project
say?
V. Engagement– SVP Partners are volunteers who assist Investees (grantees) in many areas over the 3
years we will be engaged. Our overarching goal is to build the capacity of your organization. Please
identify the top 3-5 areas listed below that are highest priority for you over the next 3 years and how
you envision using SVP resources to grow the capacity of your organization. Add comments in the
blank boxes.
Strategic Planning
Board Development and
Governance
Human Resources and
Leadership Development
Finance and Accounting
Marketing, Communications
and Public Relations
Information Technology
Other (be specific)
2016-2017 Application Form – Social Venture Partners Cincinnati
VI. Attachments (Investee Applicants only)
 Your board list with professional affiliations and board roles/responsibilities
 A list of staff and a brief description of their roles in the organization (or an organizational chart)
 Your 2014 and 2015 fiscal year end financial statements (income and expenses)
 Your FY2016 budget (income and expenses) and the YTD actual income and expenses through June, 2016
 Your most recent annual report (print or electronic) if you have one
 Your most recent strategic plan if you have one
PROPOSAL ENDORSED BY (both signatures required)
Executive Director or Chief Executive Officer
Name
Signature
Date
President or Chairperson of the Board
Name
Signature
Date
Please submit your completed application to [email protected] with all required documents by Midnight on August
15th.
Thank you for your interest and application!
Questions about your application?
Contact Lauren Merten, SVP Executive Director
[email protected]
(513) 458-6715
2016-2017 Application Form – Social Venture Partners Cincinnati