2-1-1 HelpLine Business Listing Form

In addition to submitting the below Business Listing Form, you will need to submit the 2007 Advertisement Form with your payment.

Business Listing Form
Your Information:
Name
Title
Email
Phone Number


Business Information:

Name of Business
Also Known As/AKA
Business Address:
Street
Apartment/Suite
City
State
Zip Code

Mailing Address:	Check Here if Same as Above
Street
Apartment/Suite
City
State
Zip Code


	Phone Number(s)	Phone Notes
Main Number
Fax
Toll Free
Additional Number
Additional Number


E-Mail Address
Website Address
Business Hours
Person In Charge
Title


Please Check the Appropriate Box Describing the Type of Business:
	Governmental (city)	Private, non-profit
	Governmental (County)	Private, for profit
	Governmental (State)	Private Practice
	Governmental (Federal)	Religious Affiliation
	Other (please specify)

Federal I.D.# (if applicable)


Areas Served By Your Business (check all that apply):

	Santa Barbara	Lompoc Valley
	Santa Ynez Valley	Santa Maria Valley


Please Describe All That Apply
Average Unduplicated Clients in a 30 Day Period
Ages Served:
Languages Spoken (including TTD)
If this is a Seasonal Business, enter active months
Eligibility Restrictions/Requirements
Fees
Intake Procedure

Mark all that apply:
	Handicapped Accessible	Scholarships Available
	Accommodates/Special Needs	Continuing Education
	Waiting List	Case Management
	Sliding Scale	Early Intervention Assessment
	Accept Medi-cal/MediCare	Employment Opportunities
	Provides Public Transportation Information	Provides Transportation

Please use the space below to enter suggested keywords you wish to be listed under.

Business Description: Please describe completely, but briefly, what services you offer.

Please check all information to be sure it is correct before clicking the submit button.

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