North Carolina 2-1-1
New Agency Inclusion Form
United Way Name
Address
Phone, Fax
Email
Basic Agency Information: This form should be completed by all new agencies who wish to be included in the North
Carolina 2-1-1 database. This is an online form. Simply begin typing in the gray spaces and the form will expand to allow
for unlimited data entry.
Agency Name:
Agency Physical Address
Agency Mailing Address – If Different
Please keep this address confidential
Please keep this address confidential
Street:
Street:
City, State Zip:
City, State Zip:
Agency Contact Information:
Primary Agency Phone:
Agency Email:
Primary Agency Fax:
Agency Website:
Agency Staff:
Agency Administrator:
Title:
Database Contact Person:
Title:
Phone:
Administrative and Inclusion Information
Type of Agency:
Non-profit-501(C)3
Government
Faith-based
For-Profit
Funding Sources:
United Way
Private Grants
Federal, State or Local Gov’t
Medicaid
Medicare
Years in Operation:
Less than one year
One to five years
Five years or greater
Affiliations /Accreditations:
Associated with National Organization
BBB
Other:_
__________________
Programs: Please provide a complete list of all programs offered by this agency. A program is defined as a related set of
services provided in an effort to achieve a common goal. If a program has a different physical address, eligibility criteria or
intake process it should be broken out as a separate program. Every agency must have at least one program.
1.
2.
3.
4.
5.
6.
7.
8.
9.
Important - A separate “New Program Form” should be completed for each program listed above.