CBO Contact Info Update
Organization Legal Name
Organization Alias or DBA
Submitted By
Name
Email
What are you updating?
Executive Director Information
Board Chair Information
AEC Contact
Signatory Information
Certificate of Insurance
Organization Name
Organization Address and/or Phone Number
Executive Director Information
Name
Email
Title
Phone Number
Effective Date
Demographics
Gender
Female
Male
Transgender Male
Transgender Female
Non-binary
Gender not listed
(please specify)
Race
African-American or Black
American Indian or Alaskan Native
Asian
White
Native Hawaiian or other Pacific Islander
Two or more races
Other
(please specify)
Ethnicity
Hispanic
Non-Hispanic
Age
19-24
25-39
40-54
55-64
65-74
75-84
85+
Board Chair Information
Name
Email
Phone Number
Effective Date
Expiration Date
Signatory Information
Name
Email
Phone Number
Effective Date
AEC Contact
Name
Email
Phone Number
Effective Date
Expiration Date
Organization Name
Legal Name or DBA
Publication Name
Effective Date
New Organization Address
Physical Address
Address Line 1
Address Line 2
City
State
Zip
Mailing Address
Address Line 1
Address Line 2
City
State
Zip
New Organization Phone Number
Effective Date
Certificate of Insurance
Expiration Date of Current Policy
Attach Updated COI