Thank you for sharing information
about your organization. We will include this information on our website as
well as in the 2006 print edition. Please complete the following and return it
to:
HAFISO
Resource Guide
Name of
Organization: _____________________________________________
Purpose: _____________________________________________
Contact Person(s): _____________________________________________
Street Address: _____________________________________________
Mailing Address: _____________________________________________
Telephone Number: _____________________________________________
Fax Number: _____________________________________________
Hours of
Operation: _____________________________________________
Services: _____________________________________________
_____________________________________________
_____________________________________________
Area Served: _____________________________________________
Charge for
service: _____________________________________________
Eligibility
Criteria: _____________________________________________
ATTENTION: Please have an authorized
representative of your organization sign and date this form. We cannot include
your information without a signature.
_____________________________________________ ___________________________
Name (Please print) Title
_____________________________________________ ___________________________
Signature of Authorized Representative Date
Complete the following ONLY if you
have housing facilities.
Non-Profit: YES NO
Faith-based: YES NO
Funded by: _____________________________________________
Accept Inmates: YES NO
Home Plan: YES NO
Gender: _____________________________________________
Violent/Non-violent: _____________________________________________
Sex offenders: YES NO
Number of beds: _____________________________________________
Charge for services: _____________________________________________
Staff: _____________________________________________
