California Alternate Rates for Energy (CARE)

Community Outreach Contract Application Form

Thank you for your interest in the California Alternate Rates for Energy (CARE) Program. To become a contractor of Pacific Gas and Electric Company, please fill out this application form completely, sign and return via fax to 1-800-239-6410. Application forms must be typed or computer generated. You may download additional copies of this application by visiting PG&E’s website at

Please attach:Optional, not required:

  • IRS Tax Exempt Status Form or
Federal Employer Identification Form /
  • Support materials (organizational fact
sheet, outreach examples, calendar of events,
pamphlet, newsletter or bulletin)
  • W-9 Form
/
  • Staff listing or directory

  • List of board of directors
/
  • List of awards or accomplishments

You may attach to this application any support materials or documentation you feel describe your organization or are relevant to illustrate your experience in reaching one or more of the target communities. Organizations or institutions that wish to apply as part of a coalition, please see Section IV.

SECTION I. Date of Application______

Name of Organization______

Year Established______Tax Status (Please attach proof)______

Type of Organization:  Nonprofit Private Other (explain) ______

Street Address ______

______

CityStateZip Code

Shipping Address (if different from mailing address)______

______

City StateZip Code

General Phone ( ) ______Fax ( )______

Executive Director ______Email Address______

Name

Project Manager (person assigned to CARE Outreach) ______

Email Address______

What is the total number of CARE customers your organization is committing to help enroll in the CARE program? ______

Nature of Organization, Institution or Group (Check only one of the following):

Advocacy / Human Services
Health / Recreational
Educational / Civic
Religious / Coalition/Consortium
Vocational / Other (Please explain):

SECTION II.

What expertise and/or experience does your organization or institution have with this CARE target population? This could include involvement with such public education and outreach campaigns as Healthy Families or Universal Lifeline Telephone Service with such groups as seniors, immigrants, agricultural/migrant workers or mobile home dwellers. Does your staff have any special cultural, language or other skills in education and outreach?

______

______

______

Sub-Metered Tenants

Residents of mobile home parks whose energy usage is individually metered and billed by their landlord, and tenants of other sub-metered facilities may also be eligible to enroll in the CARE Program. Should you wish to assist in enrolling these individuals, please call 1-866-PGE-CAREfor special forms and information.

SECTION III.

______

Signature of Executive DirectorDate

______

Signature of Board President or ChairDate

SECTION IV.

More than one organization, institution or group may wish to apply together as a single entity in order to participate as one CARE community-based outreach (CBO) contractor supported by Pacific Gas and Electric Company. This may appeal to organizations without individual IRS tax-exempt status or substantial resources.

In this case, one organization with proper status may serve as the lead contractor and financial agent responsible for managing the overall Pacific Gas and Electric Company contract, roles and responsibilities of participating parties (acting as subcontractors), a coordinated workplan, CARE training, enrollment materials, reporting, payments to participating parties for completed and qualified applications, and other activities as determined by the parties to the contract. There is no limit on the number of organizations that can form a CBO contractor “team.”

The organization that will lead the CBO contractor “team” should complete Sections I and II. Other participating organizations should complete the following section and attach support materials as desired.

Name of Organization______Telephone ( )______

Complete Address______

Executive Director______Signature______

Name of Organization______Telephone ( )______

Complete Address______

Executive Director______Signature______

Name of Organization______Telephone ( )______

Complete Address______

Executive Director______Signature______

Name of Organization______Telephone ( )______

Complete Address______

Executive Director______Signature______

1