Physical Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Is this address Confidential? *

Yes

No

Is your mailing address the same as your physical address? *

Yes

No

Mailing address if different than physical address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Fax

(###)

###

####

TTY

(###)

###

####

Toll Free

(###)

###

####

Director / Administrator Name *

First Name

Last Name

Administrator Phone *

(###)

###

####

Contact Name *

First Name

Last Name

Contact Phone *

(###)

###

####

I hereby certify that the above named agency meets one of the following criteria (Check all that apply): *

We are a non-profit agency, support group or governmental agency (local, county, state, federal)

We provides contracted services for a county or state organization

We offer direct services to the residents of Adams, Cumberland, Dauphin, Franklin, Perry or York Counties

We are a for profit agencies are considered for inclusion if they provide a unique human service which is not duplicated by a non-profit agency.

May we disseminate your information? *

In addition to providing information about your organization’s services over the telephone. CONTACT Helpline disseminates information in printed directories and an online database. Many social service professionals and others use this information to refer their clients to your organization and programs. Please feel free to call us at 717 652-4987 if you have concerns or questions.

YES, I hereby authorize CONTACT Helpline /PA 2-1-1 Capital Region to use my organizations information for inclusion in any print or online publication of community resources. Information that is noted as not available to the public on the form will not be given to callers, nor will it be published in other formats.

NO, CONTACT Helpline/ PA 2-1- Capital Region does not have authorization to print my organization’s information in any print or online publication of community resources. The information will continued to be provided to individuals who phone CONTACT Helpline / PA 2-1-1.

Authorized Name *

By printing your name, you hold that you are authorized to submit this application on behalf of your agency, non-profit or organization.

First Name

Last Name

Today's Date

MM

DD

YYYY