Complete the Application below and a ViTA representative will contact you within 2 business days. 

Type of Organization
Primary Contact *
Primary Contact
Phone *
Phone
http://
Please describe your organizations mission.
e.g. seniors, youth, socio-economically disadvantaged. Note: if you serve people with disabilities, please include the types of disabilities.
Location
Agreement
I understand that submission of this application does not guarantee license of ViTA-DMF will be granted.