UPCAP Services, Inc.

UPCAP Services, Inc

Agency Resource Questionnaire

Site Information
A "Site" is where programs are offered. Please complete this section for EACH Site/Satellite Office. Please complete if you have multiple sites in addition to your Administrative Office. After you complete this form, you will be given the opportunity to complete additional forms for additional sites.

Questions? Contact Melissa Kositzky at UPCAP Services, Inc.: (906) 786-4701 or simply dial 2-1-1. W e appreciate your participation in our database and look forward to referring our clients to your resources.

* Items marked with a red asterisk are required.

Official Organization Name:
If incorporated, list name as it appears in the Articles of Incorporation

Site Information

Site Name*:

Street Address*:

*City:**	*State:**	*Zip:**

Mailing Address:
If different from Street Address

City:	State:	Zip:

*Main Number:** Check if Confidential	FAX Number: Check if Confidential	Toll Free Number: Check if Confidential

TTY or Other Numbers:
Please indicate whether a telephone number should be kept confidential from the public.

Site Office Hours:

Site Director:	Title:	Phone Number: Check if Confidential

Site Area Served:

Site Hours:

Handicapped Accessibility: Please check all that apply	Is your agency or sites accessible by public transportation:
Access without special facilities Designated Parking Elevators Full Wheelchair Access Limited Access Lowered Elevator Controls No Access No Stairs in service delivery area Not applicable Ramps

Confidential/Unpublished Information:
Please include any special instructions of information that would remain unpublished but available to our call center staff when screening calls to make the most appropriate referrals.

Form Completion Information

*Form completed by:**	*Title:**

*Phone Number:**	*Date Completed:**

*Your e-mail Address:**

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