Office of Regional Operations Region 3 Registration Form for Convenings of Faith-Based and Non-Governmental Organizations

OMB Control Number: 0970-0617

Expiration date: 09/30/2026

Office of Regional Operations Region 3 Registration Form for Convenings of Faith-Based and Non-Governmental Organizations

Please complete the form below:

Name:

Email:

Mobile Phone Number:

Organization:

Photo Consent (reply "YES" only if you consent to your likeness being used in the convener's reports):

Special Accommodations (such as physical accommodations or food allergies):

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to convene a speed networking event. Public reporting burden for this collection of information is estimated to average 5 minutes per respondent, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a voluntary collection of information. Agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0617 and the expiration date is 09/30/2026. If you have any comments on this collection of information, please contact Darlene Tart-Scott at Region3ORO@acf.hhs.gov.