Agency Application

Agency/Program Name*

What programs/services do you provide?

Please list names of programs/services you offer and descriptions of them. Do not use mission/vision statements. You may instead attach a file (brochure, fact sheet, flyer, etc.) with information on your programs/services.

Physical Address

List the street address, city, state, and ZIP Code. If this is a confidential location, leave this section blank. If you have multiple locations offering the same programs/services, list them here.

Mailing Address

List the street address, city, state, and ZIP Code. If this is a confidential location, leave this section blank. If you have multiple locations offering the same programs/services, list them here.

Phone Numbers

Please indicate the types of numbers such as Administration, Office, Hotline, Customer Service, etc. List your main public contact number first.

Phone

Type

Person in Charge

Name of Person in Charge

Title

Other Contacts You Want Listed

Name

Title

We verify information in our referral database every 6-12 months.

Who should receive verification requests from us? If this person is not one of the people listed above, the contact information below will not be made available to the general public. It will be for our use only.

Verification Person's Name

Title

Website Address

Hours and Days of Operation

How do people contact you? Check all that apply.

Call

Visit Office

Visit Website

Write

Other

Who may use your services?

Languages Available? Check all that apply.

English

Spanish

Other

Volunteer Opportunities

Do you accept court ordered community service volunteers?

Yes

Donations Accepted

Do you accept monetary donations?

Yes

Do you pick up donations?

Yes

Please describe any barriers for people with disabilities trying to access your services.

What geographical area(s) do you serve? Check all that apply.

National

All of Arizona

Only the counties checked below:

Only these specific cities or geographical areas:

Federal Employer Identification Number (EIN) (if applicable):

Year your agency started offering services:

Type of Agency:

All Volunteer

Faith-Based

Government

Nonprofit

Tribal

For Profit*

* With the exception of hospitals, hospices, and utility (electric, gas, and water) companies, for profit businesses are generally excluded from our referral database. We place this limit to ensure we have the resources necessary to keep our already extensive database current. Excluding these resources does not imply disapproval of them. This is not a complete list, but these are among the most popular to apply that we do not list.

Long-term care facilities, group homes, and apartment complexes.
Day care centers and children's activity centers.
Taxi, limo, and other private transportation companies.
Individual practitioners including, but not limited to:
- Physicians and other medical practitioners
- Home health care and private nursing services
- Psychiatrists, counselors, and therapists
- Residential treatment centers and home care providers
- Substance use treatment and/or medical care, Behavioral health treatment and/or medical care.
- Lawyers, paralegals, and other legal services
- Veterinarians
- Notaries
- Real estate agents/Realtors®

Your Name*

Your Title*

Your Email Address*

All information you supply is for use by our Call Specialists and by our web-based clients. It may also be included in printed directories depending upon your area served and other qualifications. 211 Arizona strives for balance in our database and includes organizations that represent all sides of issues where such organizations are available and meet our inclusion criteria. We reserve the right to edit information for brevity, clarity, and content; and to publich the information in a variety of media, subject to confidentiality issues. When you click the button below, your application will be sent to our Resources Manager. If you supplied an email address, you should receive a confirmation email. After you submit the form, you will be returned to our website.

Phone

This field is for validation purposes and should be left unchanged.

Need Help Applying?

Contact us and a member of our team can help you apply.