Please select one:

New application

Organization information update

Name *

First Name

Last Name

Phone *

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What information would you prefer to keep private?

Any contact info NOT checked will be made available to the coalition

Organization Name

Contact name

Address

Phone Number

Email Address

Type of agency/organization and services provided:

Please check all that apply

Academia

Advocacy

Child Welfare Agency

Faith-based/Community-based

Federal Agency

Healthcare Provider

Social Services

Labor Trafficking

Law Enforcement

Legal Assistance

Legislative/Research

Nonprofit

Safe House

Sex Trafficking

Shelter

State or Local Agency

Survivor Leader

Types of clients that the agency/organization serves:

Please check all that apply

U.S. Citizens

Foreign Nationals

Adults 18+

Minors 17-

LGBTQ+

Does your organization require a background check for any of the following?

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Employees

Interns

Volunteers