Service Provider Form
Please fill out one form for each program providing services within your organization.

* indicates required fields 
  *Agency Name:
  Program:
  *Agency Mailing Address:
  *City, State, Zip:
  *Contact Person:
  *Work Phone:
  Cell Phone:
  *E-Mail Address:
  On the next line, list everyone providing services:
  *First name, Last Name, Email:
  Please indicate if you are:  County program
 State/Federal program
 Non-profit organization
 Private organization/Individual
  Check all services you would like to provide:  Medical
 Mental Health
 Dental
 Recovery Services
 Vision/Glasses
 Red Cross
 Employment
 Arts & Crafts
 HIV Services/Testing
  Check all services you would like to provide:  Legal
 Veterans
 DMV
 Shelter Svcs/Housing Info
 Entertainment
 Spiritual Services
 Credit Counseling
 Elected Officials (staff)
 Special Needs/Senior Services
 Personal care (hair care, massage, etc.)
  Benefits Assistance (GA, SSA, SSI/SSDI, etc):
  Other Services (please indicate):
  *Please indicate # of tables & chairs you need:

We expect that you will be able to provide services Tuesday (1:00pm - 4:00pm) and Wednesday (9:00am - 4:00pm). Set up is scheduled for Monday (7am-5pm) and Tuesday (6am-10am).  Tear down is Thursday AM.
We will do our best to provide you with what you need but cannot guarantee that we can provide everything.
 

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