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*
Format: (000) 000-0000.
Fax Number
Format: (000) 000-0000.
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
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
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
Format: (000) 000-0000.
Admission Contact Email
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.
Should be Empty: