Saint John Free-Net

AGENCY PROFILE FORM

	This form is for the entering of non-profit, community-based 
organizations (i.e. Canadian Red Cross, Symphony New Brunswick, and 
YMCA-YWCA of Saint John). Standard and supplemental organizational 
information for each non-profit, community-based organization can be 
entered in the following pages that will facilitate easy access by the 
public. Each page of information is administered by its appropriate member 
organization.

Organization/Group Official Name         

Abbreviated Name if Any


Contact Information
Mailing Address




City/Town/Village
                                

                     
Postal Code
                                      

                       

Province



Country




Location Address (if Different from Above)




Main Phone         EXT
                         

                    
Main Fax           EXT
                          

                    
TDD Phone
                                      

                    
Days of Operation (Regular& After Hours)
                                


After Hours Phone



Toll Free Phone



Business Hours



Program Hours




Administrator & Title    Do you wish this person published as a contact?  yes    
                                            
2nd Contact & Title      Do you wish this person published as a contact?  yes




E-mail (this must be a valid e-mail address)
               

                  
Website Address



Charitable Tax No.
                                        



Are you a United Way Agency?

              Yes


Legal Status of Agency
Non-Profit    For Profit    Federal   Provincial   Municipal   Self Help 
                                                                      

Program Delivery
Meeting Places & Times (If applicable, Support Groups, Seminars, etc.)

Days of Operation for Regular/After Hours Service 




Geographic Area Served
 
Do you offer Outreach Programs:
   
If Yes Where?
 


 Yes




Accessability for Person's With Disabilities?    Languages
 Fully                                         English
 Partially                                 French
 None                                   Other  
  
Mission Statement


Brief Description of Services & Activities


Does your Organization have a designated  Day  Month  Year

Fundraising Events planned for this year?

The following information is for use by Info-Line staff. It will not be published in the Human Services Directory or made available through the Saint John Free-Net unless otherwise indicated.

Do you wish the following information to be published? yes no

Are there any fees/dues for your services/programs? 
Is a fee subsidy available?  yes
If yes, who is eligible and what is the application process fo the subsidy?

Procedures required to apply for your orgnization's programs/services:

Criteria for service eligibilty, such as age and finacial restrictions:

Other Comments:

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