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
City	State
Zip Code	Country

Street Address *

Street Address
Street Address Line 2
City	State
Zip Code	Country

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. *

Males Females Youth Families Single-Parent Families
Choose the answer(s) that best describes your agency's target subpopulation for services. Select all that apply. *

Homeless Persons Veterans Disabled Persons Domestic Violence Victims Persons experiencing HIV/AIDS Persons experiencing Substance Abuse Persons experiencing Mental Illness Persons whom are Developmentally Delayed Persons whom are Dually-Diagnosed with specific disorders
Primary Funding Sources
Is your agency supported by the any of the following funding sources? Select all that apply. *

HUD - Rural Housing Stability Assistance Program HUD - HUD/VASH HUD:CoC - Homelessness Prevention HUD:CoC - Permanent Supportive Housing HUD:CoC - Rapid Rehousing HUD:CoC - Supportive Services Only HUD:CoC - Transitional Housing HUD:CoC - Safe Haven HUD:CoC - Single Room Occupancy (SRO) HUD:ESG - Homelessness Prevention HUD:ESG - Rapid Rehousing HUD:ESG - Street Outreach HUD:HOPWA - Hotel/Motel Vouchers HUD:HOPWA - Housing Information HUD:HOPWA - Permanent Housing HUD:HOPWA - Permanent Housing Placement HUD:HOPWA - Transitional Housing HUD:HOPWA - Short-Term Rent, Mortgage or Utility Assistance HUD:HOPWA - Short-Term Supportive Facility HHS:PATH - Street Outreach & Supportive Services Only HHS:RHY - Basic Center (Shelter & Prevention) HHS:RHY - Maternity Group Home (Pregnant & Parenting Youth) HHS:RHY - Transitional Living Program HHS:RHY - Street Outreach HHS:RHY - Demonstration Project VA - Community Contract Emergency Housing VA - Community Contract Residential Treatment Program VA - Community Contract Safe Haven Program VA - Compensated Work Therapy Transitional Residence VA - Grant & Per Diem Program VA - Supportive Services for Veterans Families VA - Domiciliary Care VAWA VOCA Privately-Funded Agency
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. Cancel of
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 participate No, we do not participate No, 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.
Membership Dues
Membership dues are now set at $10 annually for individual and agency membership of the Continuum of Care. This minimal fee is set to encourage participation from all entities that have an interest in the work of the CoC.

If you desire to purchase membership for consecutive years, you may purchase up to 3 consecutive years of agency or individual membership.

After submitting your membership request for you will recieve (via email) an invoice for your membership dues. Once receiving the invoice, payment for membership can be submitted by cash, check, or money order. All payments can be sent to the folloowing address:

MUTEH, Inc.

ATTN: CoC Coordinator

P.O. Box 24147, Jackson, MS 39225

For more information contact the CoC Coordinator at (rglenn@msbos.org)
Membership Type *

Annual CoC Membership - for Agencies/Organizations $ 10.00

Years of Membership

Annual CoC Membership - for Individuals $ 10.00

Years of Membership
Item subtotal: $ 0.00

Total $ 0.00
CONFIRMATION: I verify that all the information submitted is an accurate representation of myself or the represented agency. I also understand that this application includes a membership fee which I/we agree to pay by cash, check, or money order. *
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