2. Agency/Organization Full Legal Name:*
4. Owner Name:*
6. Business Email:*
7. Business Phone:*
9. Principal Contact Name:*
11. Email:*
12. Principal Contact Phone:*
14. Business Address:*
16. City:*
17. State:*
18. Zip:*
20. Are you a County Vendor ?*

    1. Yes
    2. No
21. If yes, what is your vendor number ?*
23. Type of service you provide:*

    1. Transitional and/or Emergency housing
    2. Transportation
    3. Mental Health, Counseling, Medical/Prescription Assistance
    4. Domestic & Sexual Assault Assistance
    5. Utilities/Rent/Mortgage Assistance
    6. Legal Assistance
    7. Children, youth
    8. Seniors
    9. Other
24. If Other, Please specify:*
26. Type of Partnership desired*

    1. Funders (leverage local, regional, and national resources through grants, foundations, and other philanthropic agencies to sponsor much of what we do)
    2. Program Partner (leverage organizations to execute our services through voluntary partnerships)
    3. Program Service Provider (supplementing organizations that coordinate with us to provide direct services to people)
    4. Project Partner (organizations who help us logistically execute our outreach and awareness efforts to highlight our services to the community)
    5. Referral Partner (organizations that refer people to our services or are organizations that we send people to for additional resources and assistance)
28. Program Description (50 words or less):*
30. Type of Business:*

    1. Profit
    2. Non-Profit
31. Number of years in existence? *

    1. 1 - 3 Years
    2. 4 - 8 Years
    3. 9 +Years
33. Website:
35. Upload company brochure/flyer if available
Leave This Blank:


37. Submit

* indicates a required field