MS Balance of State - CoC Membership Application

Membership Application

for Continuum of Care Membership
Contact Person completing this application*
E-mail of Contact Person*

Confirmation Email
Is this application for an agency/organization or individual seeking membership?*
Is this your first time applying for Membership OR are you updating your membership information?*
Agency Information
Agency Name*
Are your agency's mailing address and physical address different?*

YES, they are different. (Separate PO and Physcial Address)NO, they are the same address. (Physical Address Only)
Mailing Address*

Post Office Box

Street Address Line 2

CityState

Zip Code
Street Address*

Street Address

Street Address Line 2

CityState

Zip Code
Telephone Number*
Fax Number
Agency Web Address
Ex. www.msbos.org
Is your agency/organization a 501c non-profit?*

Yes, we are a 501c non-profit.No, we are NOT a 501c non-profit.Our 501c non-profit status is currently pending.
Is your agency a government entity?*

YES, we are a government entity.NO, we are NOT a government entity.
Is your agency a faith-based entity?*

YES, we are a faith-based entity.NO, we are NOT a faith-based entity.
Exec. Dir./President/Chief Officer's Name*
Exec. Dir./President/Chief Officer's E-mail Address*
Voting Authorization
Who is authorized to vote in the Continuum of Care on behalf of your agency?*
Periodically, there are votes that will take place on various matters. Each member agency has an individual vote.
E-mail of Authorized Voter*
Name an alternative authorized voter who is authorized to vote on behalf of your agency. Include their email address as well.
Ex. John Doe - jdoe@msbos.org
Name a 2nd alternative authorized voter who is authorized to vote on behalf of your agency. Include their email address as well.
Ex. John Doe - jdoe@msbos.org
Populations Served
Choose the answer(s) that best describes your agency's target demographic(s) for services. Select all that apply.*

MalesFemalesYouthFamiliesSingle-Parent FamiliesOther
Choose the answer(s) that best describes your agency's target subpopulation for services. Select all that apply.*

Homeless PersonsVeteransDisabled PersonsDomestic Violence VictimsPersons experiencing HIV/AIDSPersons experiencing Substance AbusePersons experiencing Mental IllnessPersons whom are Developmentally DelayedPersons whom are Dually-Diagnosed with specific disordersOther
Primary Funding Sources
Is your agency supported by the any of the following funding sources? Select all that apply.*

HUD - Rural Housing Stability Assistance ProgramHUD - HUD/VASHHUD:CoC - Homelessness PreventionHUD:CoC - Permanent Supportive HousingHUD:CoC - Rapid RehousingHUD:CoC - Supportive Services OnlyHUD:CoC - Transitional HousingHUD:CoC - Safe HavenHUD:CoC - Single Room Occupancy (SRO)HUD:ESG - Homelessness PreventionHUD:ESG - Rapid RehousingHUD:ESG - Street OutreachHUD:HOPWA - Hotel/Motel VouchersHUD:HOPWA - Housing InformationHUD:HOPWA - Permanent HousingHUD:HOPWA - Permanent Housing PlacementHUD:HOPWA - Transitional HousingHUD:HOPWA - Short-Term Rent, Mortgage or Utility AssistanceHUD:HOPWA - Short-Term Supportive FacilityHHS:PATH - Street Outreach & Supportive Services OnlyHHS:RHY - Basic Center (Shelter & Prevention)HHS:RHY - Maternity Group Home (Pregnant & Parenting Youth)HHS:RHY - Transitional Living ProgramHHS:RHY - Street OutreachHHS:RHY - Demonstration ProjectVA - Community Contract Emergency HousingVA - Community Contract Residential Treatment ProgramVA - Community Contract Safe Haven ProgramVA - Compensated Work Therapy Transitional ResidenceVA - Grant & Per Diem ProgramVA - Supportive Services for Veterans FamiliesVA - Domiciliary CareVAWAVOCAPrivately-Funded AgencyOther
Program Description Information
Upload your Program Brochures/Flyers

Upload a File
You can upload brochures or flyers that describe your programs. If the option is not available please enter the information below. Cancelof
Brief Description of Your Program(s)
Please enter a brief description of your agency programs.
Program(s) Admission/Eligibility Criteria
Please enter a brief description of your agency program criteria for eligibility.
Referral Process
Please enter a brief description of your agency program referral process.
Admission Contact Person
Admission Contact Number
Admission Contact Email
Does your agency participate in the CoC's Coordinated Entry System?*

Yes, we participateNo, we do not participateNo, but we would like to participate with our housing/supportive services
Hours/Days of Operation
Please the days and hours in which you operate.
Additional Information
If you have any other information you'd like us to know about you or your agency.
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