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Please fill out Pinellas Continuum of Care (CoC) Membership application completely. If you have any questions, please contact Victoria Kelly with the Homeless Leadership Alliance of Pinellas at VKelly@HLAPinellas.org.
Membership Type: *  
New or Renewing Membership: *  
Would you like to apply for a members scholarship?
If applying for a scholarship, please do not pay membership dues after completing this application.
Member's Information

Name: *
Title
First Name
Last Name
Suffix
Do you work, live, or go to school in Pinellas? *  
Have you experienced homelessness? *  
Date of Birth: *  
Cell Phone Number: *  
Email Address: *  
Mailing Address: *  
Address Line 1
Address Line 2
City
State
Zip
Organization (if applicable):
Job Title (if applicable):
Are you interested in joining Councils/Committees?  
Additional Information

CoC Organizational Affiliations:  
Do you have any questions?
What services are most needed in our community?  
How would you like to get involved in the CoC?
Would you like to volunteer within the CoC?  
CoC Conflict of Interest Policy

Please read and check each box that you agree to. A complete Conflict of Interest form is required annually for all membership types.
Do you agree to the Conflict of Interest Policy? *  
Voting Policy *
Disclosure *
Inquiry *
Conflict of Interest, Additional Information:  
Other

Please enter the number 1 here: *