Forms - Page 5 of 5 - North Country Homeless Services

Coordinated Entry Listing Agency Authorized User Form

Points North Housing Coalition (PNHC) providers must complete this form to request user access to the Coordinated Entry List. Only authorized users can access to the Coordinated Entry List. The first step to becoming an authorized user is completing this form. Coordinated Entry staff will verify the information received from this form and authorize access to the user.

Please review the Coordinated Entry Policies and Procedures adopted by the Points North Housing Coalition available below. The Authorized User form requires the user acknowledges their understanding of their responsibilities described in the Policies and Procedures. Therefore, users requesting access should not complete the form below without reviewing to the Policies and Procedures.

Download Coordinated Entry Policies and Procedures

The Points North Housing Coalition (PNHC) requires this form to be completed before access may be granted to the user. Upon completing all the required fields and pressing the submit button the Coordinated Entry Manager will receive the submission. If you have any questions, please us the contact us form to reach the Coordinated Entry Manager.

Name of Participating Agency *

Authorized CE LIST User *

The Coordinated Entry Priority List contains personal identifying information and only authorized users may access the CE LIST.

Title *

The title of the authorized user

Email *

Confirm Email

Please enter your email, so we can follow up with you.

Phone

In case we are unable to reach you at the email address provided.

I have received the Policy and Procedures Manual for the Points North Housing Coalition (Jefferson, St. Lawrence & Lewis Counties) Coordinated Entry System and I understand that it is my responsibility to read and comply with the policies contained in this Manual and any revisions made to it.

Yes, I received and understand my responsibilities described in the PNHC Policies and Procedures Manual

Print Name *

First

Last

Please enter your first and last name to print your name

Signature *

Please type your full name to authorize a digital signature.