PPCoC Membership Application Question Title * 1. Please provide your contact information: Name Address Address 2 City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Country Email Address Phone Number OK Question Title * 2. What organization are you representing? (List N/A if you are applying as an individual) OK Question Title * 3. Will you be the primary CoC liaison for your organization? Yes No N/A (Applying as individual) OK Question Title * 4. Member Category (Please check all that apply): Non-profit Homeless Service Provider Victim Service Provider Faith-Based Organization Government Entity Business Public Housing Agency Social Service Provider Mental Health Agency Hospital/Healthcare Provider School District Law Enforcement Veteran Service Provider Affordable Housing Developer Employment/Vocational Program Person who has experience of homelessness (current or former) Substance Use Treatment Provider Other Interested Party (please specify): OK Question Title * 5. Would you be interested in participating in any of the following committees? (check all that apply) PPCoC Ranking and Prioritization Committee PPCoC Monitoring Committee PPCoC Strategic Planning Committee Coalition of Homeless Advocates and Providers (CHAP) Youth Advisory Board (YAB) OK Question Title * 6. As a member of the Pikes Peak Continuum of Care, you must agree to the following PPCoC Responsiblities and the Conflict of Interest Policy as specified in the PPCoC Governance Charter:PPCoC Member Responsibilities:Members will vote directly to approve the governance framework set forth in the Governance Charter and any subsequent changes or additions to the Governance CharterMembers will review, update, and approve changes to the Governance Charter at least annuallyUnless the Board selection process is changed by a subsequent amendment to the Governance Charter, members will vote annually to elect Directors to available PPCoC Board positions.Members must comply with the conflict of interest and recusal process found in the § 578.95 Conflicts of interest of the Homeless Emergency Assistance and Rapid Transition to Housing Act of 2009 (HEARTH Act). For more information, review the entire PPCoC Governance Charter at the following link:PPCoC Governance Charter Agree Disagree OK DONE