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Please fill out Pinellas Continuum of Care (CoC) Membership application for Grassroots, Faith-Based, Nonprofit, Government, and For-Profit Business Partner Members completely. If you have any questions, please contact Victoria Kelly with the Homeless Leadership Alliance of Pinellas at VKelly@HLAPinellas.org.
Organization, Agency, or Business: *
Does the organization serve Pinellas County? *  
Membership Type *  
New or Renewing Membership: *  
Do you want to inquire about sliding dues scales?  
Member's Information

Name: *
Title
First Name
Last Name
Suffix
Have you experienced homelessness? *  
Job Title: *
Cell Phone Number: *  
Email Address: *  
Mailing Address: *  
Address Line 1
Address Line 2
City
State
Zip
Are you interested in joining Councils/Committees?  
New Member Information (not required for renewals)
Renewing Members, please skip to Conflict of Interest unless your organization's information must be updated.
Organization / Business's Information

Upload the following to www.bit.ly/PinellasCOI:  
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:  
Community Service Programs

If your business does NOT provide services to low- or no-income individuals and/or families, please skip to the "Additional Information" section.
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: *