CDCP Employer Application

Page 1

CDCP Application Type

Contact Type

Agency/Facility/IRIS Participant Name/CLTS Participant Name/Family Care SDS Participant

IRIS Participant, Family Care SDS, and CLTS Participants ONLY: Please enter your first name and last name as the Agency/Facility Name. Your personal information is confidential. We do not publicly share your personal information with CDCPs without your permission.

Physical Address

Address Line 2

City

State

Zip Code

Facility Website - If you do not have a website - please put n/a.

Provider License Number

If your entity/company does not have a provider license number, write 'NONE'

Entity Type:

Other, please specify

If CLTS, how are you affiliated (check all that apply)

Name of Financial Management Services (FMS)

Name of Provider/Agency

Name of Agency

Name of Parent/Guardian

Please explain further

Do you have a legal entity?

YesNo

Legal Entity Information

Legal Entity Name

Owner, licensee, or legal entity used for licensure, certification, or registry

Legal Entity Contact First Name

Legal Entity Contact Last Name

Legal Entity Phone Number

Legal Entity Email Address

Legal Entity Mailing Address

Legal Entity City

Legal Entity State

Legal Entity Postal Code

For help with the CDCP Training Registry, please contact us at:
 
Phone: 920-465-2315 or Email: cdcp@uwgb.edu

Page 2

Please enter the information of the contact person, and one alternate contact person, at your agency or facility below.

Contact Person First Name

Contact Person Last Name

Contact Person Title

Contact Person Phone Number

Contact Person Email Address

Alternate Contact First Name

Alternate Contact Last Name

Alternate Contact Person Title

Alternate Contact Phone Number

Alternate Contact Email Address