Agency Resource Questionnaire

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.

Printed forms should be mailed to:

UPCAP
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: (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.

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

Main/Administrative Office

Street Address
City, State, ZIP
Main Number *REQUIRED*
Fax Number
Toll Free Number
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
Email Address
Website Address
Contact Person
if different from Director
Title
Phone Number
Email 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
Is your agency or sites accessible by public transportation
Licenses/Certified/Accredited by
Please list all that apply
Funded By
General Agency Description/Mission Statement

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.

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.

Official Organization Name *REQUIRED*
If incorporated, list name as it appears in the Articles of Incorporation
Site Name *REQUIRED*
Street Address *REQUIRED*
City, State, Zip *REQUIRED*
Mailing Address
if different from Street Address
City, State, Zip
Main Number *REQUIRED*
Fax Number
Toll Free Number
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
Site Area Served
Site Hours
Handicapped Accessibility
Is your agency or sites accessible by public transportation
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.

Program/Service Information

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.

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.

Program/Service Name & Location *REQUIRED*
Program Contact Person *REQUIRED*
Telephone Number *REQUIRED*
Services Offered *REQUIRED*
Program Area Served *REQUIRED*
Hours/Days that Services are available
Please clarify
Description of Program Services *REQUIRED*
Application Procedure *REQUIRED*
Appointment required? Call first? Walk-in? Referral required (from whom)?
Eligibility *REQUIRED*
Age, income, residency, etc
Documents Required *REQUIRED*
What types of information should a client bring to their first visit?
Fees & Payment Information *REQUIRED*
Are pay plans available? What insurance plans are accepted?
Is the program seasonal or offered year round? *REQUIRED*
If seasonal, please list dates available

Form Completion Information

Form completed by *REQUIRED*
Title *REQUIRED*
Phone Number *REQUIRED*
Date Completed *REQUIRED*
Your e-mail Address *REQUIRED*