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Application to Join the National Suicide Prevention Lifeline
1.
Organizational Information
6%
*
1.
Name of crisis center and organization under which it operates:
(Required.)
2.
Mailing Address:
3.
Physical address (if different):
4.
Administrative telephone number:
5.
Fax:
6.
Web site address:
7.
Name of person completing form:
8.
Title of person completing form:
9.
E-mail address of person completing form:
10.
Phone number of person completing form:
11.
Crisis/Hotline Director:
*
12.
How long has your crisis center been operating in your community?
(Required.)
13.
Number of sites requesting participation in the Lifeline Network (please identify mailing and contact information for each):
14.
Is your crisis center participating in a local or statewide hotline network?
Yes
No
15.
If "Yes," please list here:
16.
If you become a member of the Lifeline Network, will that affect your participation with any of the other networks in which you are currently involved?
Yes
No
Other (please specify)
