New CoC Member Application - Dues Required

Pinellas CoC New Membership

To renew an existing membership:www.pinellascoc.org/join

Name *

Title

First Name

Last Name

Phone *

Email *

Mailing Address *

Address Line 1

City

State

Zip

Organization (if applicable)

Job Title (if applicable)

Website (if applicable)

Pinellas County Affiliation *

I live in Pinellas County

I work in Pinellas County

My organization serves Pinellas County

Pinellas CoC members must live, work, or attend school in Pinellas County, or represent organizations that serve Pinellas County. Applicants that do not meet this criteria are ineligible for membership.

Have you experienced homelessness? *

Membership Dues

Membership Type *

More information can be found on membership benefits and levels here: www.pinellascoc.org/join

Sliding Fee Scale of 50% available for:

Organizations with an annual operating budget under $500,00 or 5 or fewer employees are eligible for 50% off their annual membership dues. Organizations requesting a sliding fee scale are asked to submit a copy of their annual budget and/or organizational chart to confirm eligibility.

Membership Due Payment *

$20
$25
$50
$75
$150
$250
$300
$500
Other

Additional Information

Only applicable for those applying for membership of Grassroots Advocate, Faith-Based Partner, Government or Nonprofit Partner, or For-Profit Partner. All other applicants can skip to the next section.

Agency Programs

Please describe your program(s) that provide services to low- or no-income individuals and/or families. If you do not provide these services, please skip this question.

Program Coordinator Name/Title

Program Coordinator Phone Number

Program Coordinator E-mail

Target Population Served

Types of Housing Services

Permanent Supportive Housing

Rapid Re-housing

Transitional Housing

Emergency Bridge Housing

Emergency Shelter

Safe Haven

Other

Supportive Services Offered

Annual Budget

CoC / ESG Eligibility Requirements

Category 1: Literally Homeless

Category 2: Imminent Risk of Homelessness

Category 3: Homeless Under Other Federal Regulations

Category 4: Fleeing/Attempting to Flee Domestic Violence

Documentation Upload

This applies only to those applying for membership levels of Grassroots Advocate, Faith-Based Partner, Government or Nonprofit Partner, or For-Profit Partner. If you are applying for Community Advocate, indicate "not applicable."

Upload one of the following: *

Most recent 990 form or the organization's most recent audit

Current State of Florida (Sunbiz) Department of State certificate

501(c)(3) designation

Department of Agriculture Compliance Certification

Not Applicable

Upload documentation HERE.

Conflict of Interest

Please read the Pinellas CoC Conflict of Interest Policy.

Agreement *

I agree to the Pinellas CoC Conflict of Interest Policy

I do not agree to the Pinellas CoC Conflict of Interest Policy (ineligible for membership)

Questions and Comments

Any questions, comments, or concerns can be emailed to info@hlapinellas.org