NDHMIS User License Request

This form is for the purchase of new North Dakota HMIS User License. Each user license is $290 per user and is valid during the period of July 1 - June 30. The email used in the below request will be where the email of the issue.

Organization Name

Requestor Name

Requestor's Email

Requestor's Phone

Organization Mailing Address

Number of User Licenses

Notes

Additional notes about user licenses and if the invoice needs to be submitted to other individuals in your agency.

{name}

Do not submit passwords through this form. Report malicious form

Alert