HMIS User Access Application
User & Agency Information
Name
*
First Name
Last Name
Work Email Address
*
Personal email address (Gmail, Yahoo, etc.) will not be accepted.
Agency Name
*
Supervisor Name
What is your primary role at your agency?
*
Please Select
Intake Staff
Case Manager
Street Outreach
Program Manager
Agency Administrator
Grant Writer
Documents & Agreements
All documents must be complete, scanned (not just a picture taken from your phone), and uploaded for consideration.
Completed AND NOTARIZED Affidavit of Good Moral Character
*
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Background Check Consent Form
*
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Color Copy of Drivers License or Photo ID
*
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Existing Background Screening Results (if available)
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Submit
Should be Empty: