2015 Membership Application / Update

Organization Name:

_________________________________________________________________

Mailing Address:

__________________________________________________________________

City/State/Zip:

__________________________________________________________________

Website:

_________________________________________________________________

Primary Voting Member Name:_________________________________________________________

Primary Member Title:

___________________________________________________________

Phone: _________________________________

Fax: ______________________________________

Email: _______________________________________________________________________________
1st Alternate Voting Member - Name______________________________________________________
1st Alternate Title: ____________________________________________________________________
Phone: _________________________________

Fax: ______________________________________

Email: ______________________________________________________________________________
2nd Alternate Voting Member Name: ____________________________________________________
2nd Alternate Title:

________________________________________________________________

Phone: _________________________________

Fax: ______________________________________

Email: ______________________________________________________________________________
___ Yes, our organization would like to join LACPC. Our agency is a qualifying agency because we provide services in
Central Los Angeles. We will participate in LACPC activities in order to coordinate services and resources with an aim to
address the issues of poverty and homelessness in Central Los Angeles. The Primary Voting Member listed above, or one
preapproved Alternate Member if necessary, will represent our organization with a single vote on items requiring voting.
Membership Dues

$100

Please make check payable to Los Angeles Central Providers Collaborative and mail to: LACPC, c/o LA Mission, 303
E. 5th St., Los Angeles, CA 90013, ATTN: Herb Smith, President/CEO
Name: _______________________________________ Title: _______________________________

Signature: ___________________________________________ Date: __________________

New Member Organizations: Please complete the application below if you are applying to be a new member
organization.
Returning Member Organizations: If you are a returning member, please update any new information about
your organization.
1. Please provide the mission statement of your organization:

2. Briefly outline the populations your agency works with and the corresponding services that your
organization provides.

3. Describe the services your organization provides in Central Los Angeles:

4. What does your Organization hope to gain by joining LACPC?

5. Please complete the following table about your agency:

Beds

Annual
Bed Nights

Meals

Annual
Operating
Budget

Employment Job
Training
Placement

No. of
Programs
Operating

Volunteer
Other
Hours
(annual est.)