Reentry America Preliminary Provider Form

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1) Company Name* This field is required.
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2) Contact Email* This field is required.
example@example.com
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3) Company Contact Name* This field is required.
First Name
Last Name
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4) Contact Position (Title) * This field is required.
Owner - CEO - COO
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5) Contact Phone Number* This field is required.
Area Code
Phone Number
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6) What states do you operate in? (Select All That Apply)* This field is required.
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
(Washington DC)
West Virginia
Wisconsin
Wyoming
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7) What states do you have transitional service(s)? (Select All That Apply)* This field is required.
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
(Washington DC)
West Virginia
Wisconsin
Wyoming
Other
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8) How long has the organization or institution been established?* This field is required.
Less than 2 years
2-4 Years
4-8 years
More than 8 years
Other
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9) What transitional services do you currently provide? (Select All That Apply)* This field is required.
Banking services
Business classes
Counseling service
Bed rental (Double occupancy)
Bed rental (Single occupancy)
College Degree
Employment services
Entrepreneurship
Family Counseling
Faith-Based Intiative Workshops
Food, Clothing, Hygenical Supplies
Higher Education
ID Documentation
In-Patient Services Only
Out-Patient Services
Transportation
Voter Registeration
ALL THE ABOVE
Other
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10) What type of providership are you requesting? (Select All That Apply)* This field is required.
Community Provider - A convenient, clean and safe local housing provider.
For-Profit Provider - A local business, offering "complimentary" services.
Non-Profit Provider - A local organization, offering services for partnership.
Church Provider - Ministry outreach services, prison, homelessness, etc.
Court Provider - Judicial Reentry Services for Community Supervision.
Other
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11) How many in-mates or ex-felons are released through your program annually? (Select All That Apply)* This field is required.
100-500
500-1,500
1,500-3,000
3,000 or more
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12) What is the average security level per inmate? (Select One That Apply)* This field is required.
Low risk - No current charges, time served ( on probation )
Medium risk - some charges, felony ( on parole )
High risk - current charges, ( no parole )
Other
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13) Important Notes: ( Optional )
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REENTRY AMERICA and affiliates reserve the right to be selective. Due to the high volume of submissions you are placed on our nationwide provider list in the USA. Please allow up to 48 hours for approval or denial of your request. Upon approval a property walk-through may be scheduled in advance via management of your organization ( Please be advised ). Your signature concludes your submission.
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Apply Signature Here:
Should be Empty: