Aginglink.org

Agency Form
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Welcome to the Mid-East I&R Agency form. Please fill out the information below, and send it to us by pressing the Submit button at the bottom. It is usually a good idea to double check the information before submitting the form. Once you have submitted the data, it will appear on the screen exactly how we received it. You can make a copy for yourself selecting print from the file menu.

If you submitted the wrong information or you want to submit an update please send an update on the fields that apply.

If you have any problem submitting the form please email snelson@mideastcom.org

Information On Update:

Have you previously submitted data for this agency? Yes, No

1. Agency Name:

2. Physical Address:

City: State: Zip:

3. Mailing Address (if different):

City: State: Zip:

4. AKA/Acronym:

5. Person In Charge:

6. Title

7. Agency Type:

Check all that apply:

County	Not Classified	Religious Organizations
Federal	Private Enterprise Company	State
Membership	Public/Private Nonprofit	Volunteer
Municipality

8. Agency Phone:

Main:	National Affiliation:
Secondary:	TDD:
800:	Fax:
24-hour Number:	E-mail:

9. Days and Hours of Operation:

10. Agency Description:

11. Accessibility:

Wheelchair accessible
On site parking
On bus route
Agency transportation
TTY translators

12. Service Area:

for example: Beaufort County only, Beaufort and Pitt, statewide, etc.

13. Funding Sources:

14. Directions to Agency: