Questionnaire for Member of Employer Network


The following questions are intended to provide us with accurate representation of your
company. This information will help ensure a compatible placement of a Client within your organization.

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	Date	/ /
A. Basic Information
	Business Name
	Address
	City/State Zip
	Mailing address (if different from above)
	Phone:    ()      Fax:    ()
	Email address
	Please indicate the name of the person with the authority to authorize a job offer to a Network Client:
	Name:     Title:		Ext.
	Please indicate the contact person within your organization for the Network, if different from the person named above:
	Name:     Title:		Ext.
B. The Goals of the Nurturing Network
	The Nurturing Network is dedicated to helping any woman with an unplanned pregnancy give life to her unborn child. In particular, the Network seeks to provide a positive alternative to abortion that meets the specific needs of a woman facing a crisis pregnancy in the midst of her education or career. Because the women we serve are particularly vulnerable at this time in their lives, it is important that the support and understanding we offer be reaffirmed by the Client's employer.
	Have you, and those at your company involved in the decision to become a Network Member, read both our Client and Member brochures which describe The Nurturing Network? Yes No
	Do you feel you understand the general purposes of our organization? Yes No
	Are you, and others who would be a primary influence on a Network Client, comfortable reinforcing the goals of the Network in your association with our Client(s)? Yes No
	Do you believe that your company is capable of providing professional, supportive environment that our Client(s) may need? Yes No
	If you answered "No" to any of these questions, please briefly explain your answers below: