APPLY FOR MEMBERSHIP

Address *

Address 1

Address 2

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I consent to my website being listed and linked on CoC website's provider list

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I'm applying on behalf of: *

Individual

Entity

On which of the following committee(s) would you or your entity prefer serving?

The CoC requests each member to be involved in at least one committee. Please check at least one committee that you would like to be involved with

System Performance Committee

Program Performance Committee

Service Delivery Committee

Governance and Membership Committee

Advocacy Committee

Consumer Council

HMIS Committee

Coordinated Entry Commitee

Each member can designate 1 voting delegate, and then a secondary and tertiary delegate who can vote in their absence. Please list your delegates: Primary delegate name

Primary Delegate Name

First Name

Last Name

Secondary Delegate Name

First Name

Last Name

Tertiary Delegate Name

First Name

Last Name

Membership Acknowledgement *

I acknowledge that for my membership to be considered in good standing, I must meet the CoC by-laws definition of Active membership under Article III, Section 2 or Affiliate membership under Article III, Section 7. I also acknowledge that I have read the Member Qualifications, Duties and Responsibilities and I agree to abide by them.

Yes