2017 CoC Membership Question Title * 1. Agency Name Question Title * 2. Agency Address: Street City Zip Question Title * 3. Service Area: Kittson Roseau Lake of the Woods Marshall Polk Norman Pennington Red Lake Clearwater Norman Hubbard Beltrami Other (please specify) Question Title * 4. Primary Contact: Name (first & last): Email: Phone: Title: Question Title * 5. Contact #2: Name (first & last): Email: Phone: Title: Question Title * 6. Contact #3: Name (first & last): Email: Phone: Title: Question Title * 7. Contact #4: Name (first & last): Email: Phone: Title: Question Title * 8. Committee Choice Committee 1 Committee 2 Primary Contact Coordinated Entry Performance Evaluation Data Primary Contact Committee 1 menu Coordinated Entry Performance Evaluation Data Primary Contact Committee 2 menu Contact #2: Coordinated Entry Performance Evaluation Data Contact #2: Committee 1 menu Coordinated Entry Performance Evaluation Data Contact #2: Committee 2 menu Contact #3: Coordinated Entry Performance Evaluation Data Contact #3: Committee 1 menu Coordinated Entry Performance Evaluation Data Contact #3: Committee 2 menu Contact #4: Coordinated Entry Performance Evaluation Data Contact #4: Committee 1 menu Coordinated Entry Performance Evaluation Data Contact #4: Committee 2 menu Question Title * 9. Our agency has read and agrees to the Membership Agreement and Code of Conduct. Yes No Submit