CSBG Service Provider Updates

The purpose of this survey is to capture all of the relevant contact information for our CSBG network.

Question Title

1. 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:

Question Title

2. 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)

Question Title

3. Please indicate all the CSD FUNDED PROGRAMS the agency administers:

LIHEAP (HEAP)

LIHEAP(WX)

DOE(WX)

Naturalization

Prisoner Re-entry

Other (provide brief explanation)

Question Title

4. Please provide requested information for the EXECUTIVE DIRECTOR of the agency.

Executive Director Name:

Title:

Direct Phone Number:

Direct Fax Number:

Email Address:

Question Title

5. 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:

Question Title

6. 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:

Question Title

7. 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:

Question Title

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.

Yes

Additional Agency Information

Question Title

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.

Yes

Additional Agency Information