CSBG Service Provider Updates
The purpose of this survey is to capture all of the relevant contact information for our CSBG network.
1
. Please provide only BASIC AGENCY information (more specific information will be asked in additional questions).
Please provide only BASIC AGENCY information (more specific information will be asked in additional questions).
Agency Name:
Physical Address:
Mailing Address: (if different than above)
City:
ZIP Code:
General Phone Number:
General Fax Number:
Agency Website Address:
2
. Please indicate TYPE OF AGENCY:
Please indicate TYPE OF AGENCY:
Public Agency
Private Agency
Limited Purpose Agency (LPA)
Native American Indian (NAI)
Migrant Seasonal Farm Worker (MSFW)
Other (please specify)
3
. Please indicate all the CSD FUNDED PROGRAMS the agency administers:
Please indicate all the CSD FUNDED PROGRAMS the agency administers:
LIHEAP (HEAP)
LIHEAP(WX)
DOE(WX)
Naturalization
Prisoner Re-entry
Other (provide brief explanation)
4
. Please provide requested information for the EXECUTIVE DIRECTOR of the agency.
Please provide requested information for the EXECUTIVE DIRECTOR of the agency.
Executive Director Name:
Title:
Direct Phone Number:
Direct Fax Number:
Email Address:
5
. Please provide requested information for the CSBG PROGRAM MANAGER of the agency.
Please provide requested information for the CSBG PROGRAM MANAGER of the agency.
CSBG Program Manager Name:
Title:
Direct Phone Number:
Direct Fax Number:
Email Address:
6
. If you have more than one CSBG PROGRAM MANAGER, please provide their information here.
If you have more than one CSBG PROGRAM MANAGER, please provide their information here.
CSBG Program Manager Name:
Title:
Direct Phone Number:
Direct Fax Number:
Email Address:
7
. Please provide requested information for the CHIEF FISCAL OFFICER (or equivalent) of the agency.
Please provide requested information for the CHIEF FISCAL OFFICER (or equivalent) of the agency.
Chief Fiscal Officer Name:
Title:
Direct Phone Number:
Direct Fax Number:
Email Address:
8
. Does the agency have a CSBG ARRA PROGRAM MANAGER, different from your regular CSBG program manager, that CSD should be aware of for proper communication? If so, provide the contact information below.
Does the agency have a CSBG ARRA PROGRAM MANAGER, different from your regular CSBG program manager, that CSD should be aware of for proper communication? If so, provide the contact information below.
Yes
No
Additional Agency Information
9
. Does the agency have OTHER CONTACT INDIVIDUALS or INFORMATION that CSD should be aware of for proper communication? If so, provide the information below.
Does the agency have OTHER CONTACT INDIVIDUALS or INFORMATION that CSD should be aware of for proper communication? If so, provide the information below.
Yes
No
Additional Agency Information
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