Provider Setup (WCCAC)
Agency Name *
Your answer
Provider Name *
name of your program
Your answer
Fiscal Year Start Date *
MM
/
DD
Fiscal Year End Date *
MM
/
DD
Address *
street, city, state, zip
Your answer
Main Phone *
Your answer
Website
Your answer
Director Name *
Your answer
Director Email *
Your answer
Director Phone *
Your answer
HMIS Contact Name *
Your answer
HMIS Contact Email *
Your answer
HMIS Contact Phone *
Your answer
Project Type *
Target Population *
Services Provided (required by grant) *
list all separated by a comma
Your answer
Services Provided (optional)
list all separated by a comma
Your answer
If shelter, total # of beds
Your answer
If PH, total # units
Your answer
If PH, total # of beds
Your answer
Comments
Your answer
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