NYS Coalition for the Aging

Community Senior Providers

Please fill out the form below.

Organization Name
Contact Name:
Address:
City:
State:
Zip:
Phone:
Fax:
E-mail:
Website Address:
Counties Served:
Brief Description of your Organization:
Services You Provide:
Are there fees for your services?	yes no
If so, which one's, and how much:
What days and hours are you open?
Other? (anything else people should know about you?):
Do you have events throughout the Year you would like posted? Please list the month and the event below as well as a contact person and their phone number.
I would like to be linked to your website for a $25 per year posting fee	Yes No
I would like my associaition members listed for $500 per year	Yes No
Thank you- You will be invoiced for the appropriate amount.

If you have any questions or suggestions, please do not hesitate to call us at 518-465-0641.