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Please fill out the Pinellas Continuum of Care (CoC) Membership application for Nonprofit Organization / Government Agency Partners completely. If you have any questions, please contact Victoria Kelly with the Homeless Leadership Alliance of Pinellas at VKelly@HLAPinellas.org.
New or Renewing Membership: *  
Organization or Agency: *
Does the organization serve Pinellas County? *  
Primary Member's Information

Name: *
Title
First Name
Last Name
Suffix
Job Title: *
Cell Phone Number: *  
Email Address: *  
Address: *  
Address Line 1
Address Line 2
City
State
Zip
Are you interested in joining Councils/Committees?  
Designee Information (if applicable)
Authorized to act on behalf of Primary Member

Designee's Name:  
Designee's Title:  
Designee's Phone Number:  
Designee's Email Address:  
New Member Information (not required for renewals)
Renewing Members, please skip to Conflict of Interest unless your organization's information must be updated.
Organization / Agency's Information

Documentation:  
What is your organization's mission?
Does your organization practice Housing First?  
Annual Budget of Organization / Agency:
Website:
Facebook Handle or Link:  
Twitter Handle or Link:  
Instagram Handle or Link:  
LinkedIn Handle or Link:  
YouTube Handle or Link:  
Does your organization have more than one program?
What is / are the name(s) of your program(s)?
Program Coordinators' Name, Title, Phone, & Email:  
Program or Agency's Eligibility Requirements:  
Program or Agency's Target Population(s):  
Does your organization offer housing services?  
Does your organization offer supportive services?  
May we list this program in resource guides?  
Additional Information

CoC Organizational Affiliations:  
Do you have any questions?  
What services are most needed in our community?  
Would you like to volunteer within the CoC?  
CoC Conflict of Interest Policy

Do you agree to the Conflict of Interest Policy? *  
Voting Policy *
Disclosure *
Inquiry *
Conflict of Interest, Additional Information:  
Other

Please enter the number 1 here: *  

Membership dues for Nonprofit or Government Partner Members are $300.00 annually.

If you have not already, please upload the following information (if applicable) to www.bit.ly/PinellasCOI; you may also email these documents to VKelly@HLAPinellas.org:

- 501(c)(3) designation
- The most recent 990 form or the organization's most recent audit
- The organization's current Department of Agriculture compliance notice
- The organization's current State of Florida (Sunbiz), Department of State certificate