1. * Name
2. Organization Type Nonprofit Legal Services ProviderAdditional Legal ServicesCourtClothingCommunity ServicesEmploymentFaith Based ServicesFood PantryHealth & Mental HealthLaw Enforcement & SafetyPrivate Law FirmShelterTransportationVictim ServicesVictim Transitional AssistanceReentry servicesIn-prison assistanceLegal clinicsNonprofit ServicesOther
3. Description
4. * Address Line One
5. Address Line Two
6. * City
7. State Other AL - Alabama AK - Alaska AZ - Arizona AR - Arkansas CA - California CO - Colorado CT - Connecticut DE - Delaware DC - District of Columbia FL - Florida GA - Georgia GU - Guam HI - Hawaii ID - Idaho IL - Illinois IN - Indiana IA - Iowa KS - Kansas KY - Kentucky LA - Louisiana ME - Maine MD - Maryland MA - Massachusetts MI - Michigan MN - Minnesota MS - Mississippi MO - Missouri MT - Montana NE - Nebraska NV - Nevada NH - New Hampshire NJ - New Jersey NM - New Mexico NY - New York NC - North Carolina ND - North Dakota OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania PR - Puerto Rico RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VT - Vermont VI - Virgin Islands VA - Virginia WA - Washington WV - West Virginia WI - Wisconsin WY - Wyoming AB - Alberta BC - British Columbia MB - Manitoba NB - New Brunswick NL - Newfoundland and Labrador NT - Northwest Territories NS - Nova Scotia NU - Nunavut ON - Ontario PE - Prince Edward Island QC - Quebec SK - Saskatchewan YT - Yukon Territory
8. * Zip Code
9. Display Address?
10. Phone Number
11. Fax Number
12. TTY Number
13. Email Address
14. Site URL
15. Map URL
16. Provides free or low-cost application services
17. How much are you charging per application? AnonymousLess than $100$100 - $200$201 - $300More than $300
18. How many representatives do you have on staff? 12-34-55-10More than 10None
19. How many interpreters do you have on staff? 12-34-5More than 5None

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2. Organization director or executive director
3. First Name
4. Last Name
5. Phone
6. Email
7. Person filling out form
8. * First Name
9. * Last Name
10. * Phone
11. * Email
12. * Verification
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