Basic Agency Information: This Form Should Be Completed by All New Agencies Who Wish To
Ann Watson
United Way’s NC 2-1-1
Phone: 919-361-8437
Program Contact Information: This program form should be completed for each program associated with an agency.Begin by typing in the gray spaces and the form will expandto allow for unlimited data entry.
Please fill out a separate form for every service, especially if the contact numbers, address, eligibly, or intake are different.
Controlling Agency Name (ex. DSS):
Program Name (Please complete separate forms for each program. ex. Medicaid):
Official Contact Name for Updates : / Official Contact Email for Updates:
Program Physical Address
Please keep this address confidential / Program Mailing Address – If Different
Please keep this address confidential
Street: / Street:
City, State Zip: / City, State Zip:
Phone and other contact information
Please enter all relevant phone numbers, including specialized hotlines or intake lines that may be helpful to callers.
Same as Agency
Phone Number - Main:
Phone Number #2 and Description:
Phone Number #3 and Description:
Phone Number #4 and Description:
Program Fax:
Email: / Website:
Program Contact: / Title: / Phone:
Program Information
Please provide as much detailed information as possible so that only appropriate referrals are directed to your program.
Service Description (Please provide a complete description of all services offered by the program)
Landmarks / Directions (Ex. On Elm St, between Main and High Streets, next to the post office)
Hours of Operation (Ex. Monday - Thursday, 8:00 a.m. - 5:00 p.m)
Program Fees (Please describe all fees associated with services.)
Areas Served (Is the service limited to residents of a specific county, zip codes, or neighborhood?)
Intake Procedure (How do clients apply for services?)
Eligibility Criteria (Please describe all eligibility criteria including: age, gender; residence, previous service, education and income guidelines where appropriate.)
Languages (Please list all languages other than English in which services are provided):
Volunteer Needs:(Not Needed for Buncombe, Rutherford, or Transylvania Counties) (Does your organization use volunteers and in what capacity?)
Donation Needs(What equipment or supply needs does your organization need?)
Documentation Required(ex. Picture ID, Social Security Card, Birth Cert., Income Verification, Shut-off notice, Eviction Notice, Proof of insurance)
Accessibility(ex.Wheelchair Accessible, On Bus Route, Program Transportation)
Legal Status: (**To be included,official documentation of legal status is required **)
Non-Profit (this includes any tax exempt, non-profit organization)
For-Profit (See inclusion criteria)
Public Service (this includes Government, City ,County, State Offices such as Dept. of Social Services, Federal Program
Organizations such as USDA)
Additional Information:
2-1-1 of North Carolina is collecting this information to include in a public resource database for community information and referral. We may make changes in order to ensure compliance with database style and indexing needs.
2-1-1 needs to officially verify each listing once per year, but please contact us if you need to make changes anytime.
By completing this form youare agreeing to comply with requests for information from 2-1-1ofNorth Carolina.
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