| Organization Name: |
  |
| Other Names Used? |
Yes No |
| If yes, what other names? |
|
| Are you registered with the New York, Department of State, Bureau of Charitable Organizations? |
| If so, please enter your Certificate of Registration Number. |
|
| Date your current certificate expires. |
|
| Phone Number: |
ext. |
| Secondary Phone Number: |
ext. |
| TDD Phone Number: |
ext. |
| Fax Number: |
|
| Internet Address (URL): |
http:// |
| Mailing Address 1: |
|
| Mailing Address 2: |
|
Resident County:
(click on the  below to display a listing of Minor Civil Divisions) |
|
|
| City: |
|
| State: |
|
| Zip Code: |
|
Only complete if different from mailing address!
|
| Street Address 1: |
|
| Street Address 2: |
|
| City: |
|
| State: |
|
Zip Code:
|
|
|
How to find us/
Parking Instructions: |
|
| Main Entrance: |
|
Other Offices
and Locations: |
|
Days & Times
of Operation: |
|
Days & Times of
Regular Meetings: |
|
| Meeting Locations: |
|
Mission, Purpose,
& Vision: |
|
Services, Programs,
& Products: |
|
If this organization is a unit, branch or affiliate of a larger
organization registered in Community Assets NY, please choose that
organization's name from the pull down menu. |
|
|
| Please list us in the following community categories (click the category name for the definition): |
|
|
Counties Served (Check one or more):
(click on the below to display a listing of Minor Civil Divisions) |
|
|
| |
|
| First, MI, Last Name: |
|
| Title: |
|
| Phone: |
ext: |
| Email: |
|
|
Please choose a username and password below to log into the site. |
| Username: |
|
| Password: |
|
| Confirm Password: |
|
| Profile submitted by: (fill out only if you are not the person listed in the answer immediately above): |
| First, MI, Last Name: |
|
| Title: |
|
| Phone: |
ext: |
| Email: |
|
|
| First, MI, Last Name: |
|
| Title: |
|
| Phone: |
ext: |
| Email: |
|
Would you like to be contacted directly from this site by users?
"Yes" will require an email address below
Email:
|
Community Assets NY Core Profile Waiver |
| I certify that all statements made in this core
profile form are true. I commit to keeping this information current by reviewing and updating the
information periodically. I understand that by submitting this core profile form, once the registration
has been approved, the data I supply will be automatically posted to The Yellow Pages in Community Assets NY's on-line database. All parties using this site will have access to this information. |
| |
| Community Assets NY does not endorse any of
the registered organizations, their products, services or activities. Users of this database are
solely responsible for any use made of any and all of its contents. |
| |
| I understand that once my registration has been
approved, I will also be able to post information to the Community Calendar, Search for
Help and Volunteer Center. Such information may be viewed by any registered
and/or non-registered users of the CANY database. The purpose of CANY is
to create a single point of access on the World Wide Web that supports the good and welfare of people
served by this site. I certify that any information I post to CANY will be true and
accurate and that I will not willfully post false or inaccurate information. I understand that use
of CANY is a privilege managed by its operators and not an absolute unmonitored right.
The Community Action Association of New York (NYSCAA) reserves the right to reject or accept all entries submitted.
|
| |
By clicking on the Submit button below, I
certify that I have read, understood, and accepted all of the above statements, terms, and conditions.
Are you human? Enter the numbers in the image into the text box.
|
*Required for registration verification.
|
