PSNH and NH 2-1-1

AGENCY INFORMATION 1. The Agency Information Form asks specifically for information about your agency headquarters. This form is used to add an agency to the 211NH database. If you only want to make changes to the information we already list please see the UPDATE/DELETE FORM. 2. If your agency has other locations please complete the SITE INFORMATION FORM 3. Please complete the SERVICE INFORMATION FORM for EACH program that your agency offers.

Agency Name: Address (include street, city, state, and zip): Phone toll free: Administrative Phone: Service/Intake Phone: Fax: Website: http://www. Main Email: Agency Director: Title: Phone: Email: Contact for Annual Update: Title Phone: Email: Month for survey to be emailed: Send email survey to: Agency/Administrative Office Branch/Service Location(s) Agency Type: (Please select only one) Non-Profit For Profit Government Educational Public Religious Coalition/Other Group Facility Type: (Please select only one) Church/Synagogue Government Office Health Care Phone Service Only School Public Safety Website Only Independent Organization Accessibility: (Please check as many as apply) One-Level Building Elevators Ramps Limited Access Stairs Only Some Stairs Designated Parking On-Street Parking Only N/A Funded by: (Please check as many as apply): Contracts United Way Donations Fees FEMA Grants City Funding County Funding State Funding Federal Funding Corporation/Foundation Funding Independent Fund Raising HUD IRS Status Code: Year Incorporated: Tax ID: Administrative Hours: Days: Hours: Agency Service Summary:

Don’t forget to complete the SERVICE INFORMATION FORM found on our website!

2-1-1 New Hampshire  PO Box 211  Manchester, NH 03105 www.211nh.org [email protected]