Follow the steps to successfully complete the application form.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Begin filling out the personal details at the top of the form. Provide your name (last, first, middle initial), license/certification number, expiration date, and National Provider Identification number.
3. Select your discipline by checking the appropriate box: Physical Therapist, Speech/Language Pathologist, Occupational Therapist, Licensed Clinical Social Worker, or Licensed Psychologist.
4. Enter your mailing address, work and cell phone numbers, and email address in the designated fields.
5. Attach a brief description of any specialized training you have received related to serving individuals with intellectual/developmental disabilities.
6. Indicate whether you have two years of experience serving individuals with intellectual/developmental disabilities in the United States by checking 'Yes' or 'No.' If 'Yes,' attach a description of your experience, including the length of time and any relevant agency affiliations.
7. Answer the question regarding any professional misconduct or disciplinary actions. If applicable, attach a detailed explanation.
8. Attach your resume, ensuring it includes your education and clearly illustrates how you meet the qualifications required.
9. Complete the attestation by printing your name, signing the form, and dating it.
10. If necessary, have the document notarized. Complete the required sections including the county and date.
11. Once you have filled out all sections and attached necessary documentation, save your changes. You can then download, print, or share the completed form as required.

Complete your application form online to ensure your approval to provide vital services.