Agency Information Form

Please complete the following to provide us with information about your agency. Once submitted, please complete a separate Service Information Form for each service your agency offers.

If you have any questions, please e-mail resource@unitedwayoc.org

Agency Name *
(Legal name of the agency)

Other names the agency may be known by

Agency Description *

Do you offer additional services during Public Safety Power Shutoff (PSPS) events? *

Yes

No

Description *

Agency Headquarters/Main Office Address *

Select One... Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick Newfoundland New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northwest Territory Nova Scotia Nunavut Territory Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory

Is this address confidential? *

Yes

No

Please select the type of disabilities access this location has

Fully accessible to individuals using mobility aids

Potential limitations to access in some service areas – call for details

Designated, accessible parking spaces

Service area is not accessible

Mailing address same as physical address

Mailing Address *

Select One... Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick Newfoundland New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northwest Territory Nova Scotia Nunavut Territory Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory

Agency Phone *

Agency Office Hours

Agency E-Mail *

Agency Website

First Name *

Last Name *

Title *

Phone *

Email *

Are you the Primary Contact person for this agency? *

Yes

No

Primary Contact's Name *

Title *

Direct Phone *

Direct Email *

Are you the Executive Leader of this agency? *

Yes

No

Executive Contact's Name *

Title *

Direct Phone *

Direct Email *

Is your agency interested in becoming a GetHelpOC enhanced service partner? To learn more check yes and a 211OC representative will reach out with more information (GetHelpOC.org). *

Yes

No

Agency Type *

Non-Profit 501(c)

Government

For-Profit

None

I'm not a robot *