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Request to Include Your Program or Service in Arkansas Civiform.

Request to include your program or service application form in Arkansas Civiform.

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Use this form to request the inclusion of your referral form or application for a government-sponsored or local community program in Civiform. It is not intended for promoting or advertising for-profit personal businesses.

Please enter your name

What is the name of the organization or agency that you represent?

Are you with a community-based organization that is offering services or are you representing a government agency?

Are you with a CBO or a government agency?

Is your organization registered as a non-profit with the State of Arkansas?

Arkansas Code Annotated § 4-28-401 through 416 sets out the registration and reporting
requirements for charitable organizations, paid solicitors, professional telemarketers, and fund-raising
counsel.

Please briefly describe the programs and services you offer.

Please indicate how many caseworkers work for your organization who may also need access to apply for benefits on behalf of clients. We will work with you to get them set up.

Some answers on this page need to be fixed

This page of your application either has some errors or some fields were left blank. If you continue to the previous page, none of the information entered on this page will be saved until the errors are corrected.