UPCAP Services, Inc.

UPCAP Services, Inc

Agency Resource Questionnaire

The information requested in this form will be used to refer callers throughout the Upper Peninsula of Michigan who are seeking services and volunteer opportunities in their communities. Your accurate detailed information will better help us refer callers appropriately and efficiently. PLEASE complete the online form below. Or, if your prefer to mail or fax your form, a printable version is available in PDF format. Click here to download the PDF form.

Printed forms should be mailed to:

UPCAP Services, Inc
Attn: Melissa Kositzky
P.O. Box 606
Escanaba, MI 49829

or fax the completed form to (906) 786-5853.

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

NOTE: Program/Service Information
To go directly to the Program/Service Information Form click here.
NOTE: Site Information
To go directly to the Site Information Form click here.

* Items marked with a red asterisk are required.

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

Main/Administrative Office

Street Address*:
Check if Confidential

*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.

Administrative Office Hours:

Agency/Organization Director:	Title:	Phone Number: Check if Confidential

E-mail Address:	Web site address:

Contact Person: (If different from Agency Director)	Title:	Phone Number: Check if Confidential

E-mail Address:	Federal ID Number (optional):

Other/Previous or AKA Organization Name:
Register assumed names, other common names

Agency Type: Please check one	Handicapped Accessibility: Please check all that apply
501 (c) (3) Church Affiliated Coalition or Other Group For Profit Private, Non-Profit Proprietary Public - City Public - County Public - State Public - Federal Support Group	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

Is your agency or sites accessible by public transportation:

Licenses/Certified/Accredited by:
Please list all that apply.

Funded By:

   United Way
   Corporation/Foundation
   Donations
   Federal Funding
   State Funding
   Other

General Agency Description/Mission Statement:

Form Completion Information

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

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

*Your e-mail Address:**

PLEASE READ:
Once you have entered all the information above, please click "CONTINUE" below. We will then ask you questions regarding the Site Information.

Home || UPCAP Info || UPAAA || Family Caregiver Network || Long Term Care || UPACC || Housing Development || Other Programs