
D 19.1001-19.1023 and that the information provided on this form and on any attachments is true and correct. I authorize any changes requested on page 2. NO SIGNATURE REQUIRED LHL367 10/2009 Page 1 of 2 CHANGES ONLY MAY BE FAXED TO 512-490-1054 REQUEST CHANGES ONLY: COMPLETE ONLY ITEMS THAT HAVE CHANGED Feel free to use a separate sheet of paper, if there is not enough room on this form Firm Name or Alias.
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How to fill out the Form Lhl367 online
The Form Lhl367 is essential for users looking to renew their continuing education provider registration or change contact information. This guide provides clear, step-by-step instructions on how to accurately fill out the form online.
Follow the steps to successfully complete the Form Lhl367.
- Click ‘Get Form’ button to obtain the form and open it in the editing interface.
- Begin by completing the Education Provider Identification section. Fill in your TDI Provider Number, Provider Name, and Provider's Trade Name or DBA.
- If your address, phone numbers, email address, or approved provider representative has changed, complete the appropriate fields on page 2.
- If you are renewing the provider registration, answer the screening questions. Indicate whether there have been any certifications or approvals revoked, suspended, or placed on probation.
- For corporations, LLCs, or banking corporations required to pay franchise tax, attach the appropriate letter of good standing or exemption from the Texas Comptroller’s office.
- Complete the attestation section by certifying that you and your authorized provider representative have read and will comply with all requirements. No signature is required.
- If you are only making changes, ensure to complete only those items that have changed on page 2. Use a separate sheet if necessary.
- After filling out the form, you can save your changes, download the document, or print it for your records.
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