Instructions on how to fill out this form.

Welcome to the Mideast 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 Mtabak@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: