Plantory Member Application
Date
Your answer
Type of membership
Full-Time Membership ($275/mo)
Part-Time Membership ($100/mo)
Student Membership ($75/mo)
Mailbox Membership ($25/mo)
Day Pass ($10/day either billed as invoice or paid at the Front Desk)
Sponsored Membership (Varies)
Number of Desks Requested
1 part-time membership
1 assigned workspace
2 assigned workspaces
3 assigned workspaces
Other:
Name of Organization/Project
Your answer
Current Address
Your answer
Contact Person
Your answer
Telephone #1
Your answer
Telephone #2
Your answer
Email
Your answer
Website
Your answer
Facebook
Your answer
Organizational Information
Additional Members Sharing the Space, phone numbers, email
Your answer
Organization's FEIN - Federal Identification Number
Your answer
Organization's KY SOS - Ky State Organizational Number
Your answer
When was the Organization/Project started?
Your answer
Mission
Your answer
What makes your work socially innovative or important?
Your answer
What is the target demographic/population for your programs and projects?
Your answer
Organization Sector
Environment/Animals/Sustainable Living
Arts
Social Justice
Health and Disability
Technology
Community/Economic/Workforce Development
Public Space
Professional Association
Law/Advocacy/Politics
Social Services/Civic or Volunteer Services
Recreation
Capacity Builder
Youth/Children/Families
Faith/Religious/Spiritual
Other:
Stage of the Organization
Emerging/Start-up
Growing
Sustained and Stable
Organization Type:
Collaborative
Social Enterprise
Social Purpose Business
Entrepreneur
Consultant
Sole Proprietorship
Artist
Other:
Legal Structure
501c3 Non-profit
For profit business
Unincorporated
Other:
Statistical Information
Staff Size
0-2
3-5
6+
Other:
Average Total Weekly Hours of Desk Use
(for entire staff)
Your answer
Volunteer Staff
0-2
3-5
6+
Other:
Average Total Weekly Hours of Desk Use
(for volunteer staff)
Your answer
Please tell us about your current programs and projects.
Your answer
# of people served through your programs and projects
Your answer
Recent Grants Applied for and Received
Your answer
Since the program/project start date, please explain any applicable organizational changes (expansion, reduction, funding changes, etc.)
Your answer
Operating Budget
Your answer
Plantory Connection
Please tell us why your organization is a good fit for co-working at the Plantory
Your answer
How do you hope to connect with the organizations in the Plantory?
What types of relationships are you looking to build, what kinds of resources do you have to share with your neighbors, what resources are you hoping to find in the Plantory community, etc.
Your answer
The location of the Plantory is
Not Important
1
2
3
4
5
Very Important
24-hour access is
Not Important
1
2
3
4
5
Very Important
Access to meeting space is
Not Important
1
2
3
4
5
Very Important
The reputation of the Plantory is
Not Important
1
2
3
4
5
Very Important
Working with like-minded organizations is
Not Important
1
2
3
4
5
Very Important
Sharing resources with like-minded organizations is
Not Important
1
2
3
4
5
Very Important
Having a healthy work environment is
Not Important
1
2
3
4
5
Very Important
If you would like to offer any additional information concerning your organization, projects, funding, staff, etc., please do so here
Your answer
Plantory Development
Are there other organizations that you would like to see join The Plantory? Please give us their contact information. Thank you!
Your answer
Do you have any ‘wish list’ items? (i.e. Amenities that you would like The Plantory to offer?)
Your answer
Are there specific training topics that you would like our programming to incorporate?
Your answer
Are you interested in having support from the Plantory interns? If so, what type of projects do you hope to get their help with?
Your answer
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