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New program for CIC Database
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Please provide the following information if you have a new service that 
is not listed in our database. Please print.

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  Official name:
 Alternate name:
  Parent agency:

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Contact Information:
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Mailing address:
       Location: ( ) address above, or
                 ( ) different location:

Phone numbers
            tel:
            fax:
            tdd:

Internet
            web:
          email:

Contact person
           name:
          title:
            tel:
          email:

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Service Information:
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    Eligibility:
    Area served: ( ) no restriction, or
                 ( ) geographic boundaries:

    Description:







   Hours, Dates:
           Fees:
    Other info?:





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Source of Information:
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           Name:
          Title:
           date:
            tel:
          email:

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Return to:
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                 Community Information Centre of Waterloo Region
                 151 Frederick St, Ste 300, Kitchener N2H 2M2
            tel: 579-1096
            fax: 578-9185
          email: info@waterlooregion.org