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Community Services Directory Intake or Data Correction Form

Enter information in the form below as you want it
to appear in directories such as the Community Services Directory or
www.BeehiveSacramento.org
(see requirements to join our directory)

Agency Information
* indicates REQUIRED INFORMATION

* Agency Name (maximum 50 characters): 
AKA (also known as, acronyms, former or popular name):
Year of Incorporation: - If not a government agency, a copy of your 501(c)(3) will be requested
Street Address: (maximum 35 characters):
City:     State (2-letter code):     ZIP code:
Mailing Address (if different) (35 characters):  
City:     State (2-letter code):     ZIP code:
Telephone 1  -
    Office  Info Line Answering machine or service   24-hours     TDD
Telephone 2  -
    Office  Info Line   Answering machine or service   24-hours     TDD
Telephone 3  -
    Office  Info Line   Answering machine or service   24-hours     TDD
Telephone 4  -
    Office   Info Line   Answering machine or service   24-hours     TDD
FAX   -   Email:
Web Site:      
Funding Sources: Dues/memberships Contracts Contributions (In-Kind) Fees (fee for service)
 Endowment  Faith based (Church) Fundraising Medi-cal/Medicare Private Donations
 Private Insurance Grants/private   United Way   City County State Federal Sales
School/School Districts
Purpose or Mission of Agency: 
Days & Hours (50 characters):
Person In Charge (30 characters) :    Title (25 characters):

Agency Type:
 Nonprofit    Support Group  Association  Club  Church  Profit School District   City 
County    State     Federal    Special District  Joint Power Media  Public
 Other


 

Program/Client Services Information

* Program Name (maximum 50 characters):
AKA (also known as, acronyms, former or popular name):
Street Address: (maximum 35 characters):
City:     State:     ZIP code:
Mailing Address (if different) (35 characters):  
City:     State (2-letter code):     ZIP code:
Telephone 1  -
    Office  Info Line Answering machine or service   24-hours     TDD
Telephone 2 -
    Office  Info Line Answering machine or service   24-hours     TDD
Telephone 3  -
    Office  Info Line Answering machine or service   24-hours     TDD
Telephone 4  -
    Office  Info Line Answering machine or service   24-hours     TDD
FAX   -   Email:
Web Site:      
Person In Charge (30 characters) :   
Title (25 characters):
Days & Hours (50 characters):
Description of Services
Population service is intended for:
Services Aids (check all that apply):
   Architecturally accessible     Near bus lines    Light rail    Transportation Available
  Parking available    Use volunteers        
Fees/Method of Payment (126 characters):
Languages Spoken (besides English):
Eligibility (60 characters):
Area Served (geographical such as ZIP code, city, county, area, etc.)
(60 characters):
Application/Intake Procedure (check all that apply):
 Email    Other: 
Telephone  Walk-in  Web site  Write  Referral from:
Required Documents:
Other Requirements/procedures:

I agree that all information may be made public via InfoLine Sacramento, printed products such as Community Services Directory, or online websites such as BeehiveSacramento.

Yes
No

* Name of person completing this form 

* Email

* Direct Phone (not agency) 

      * Date 
Thank you!
 
Community Services Planning Council, 2006

909 12th Street