Follow the steps to complete the form accurately.

1. Click the ‘Get Form’ button to access the form and open it in your preferred editing tool.
2. Identify and check one of the options under 'Check One' which includes: 'New Agency', 'Update / Change Agency', or 'Additional Agency' based on your situation.
3. Provide the name and credential number of the agency affiliated applicant in the specified field, ensuring that the information is printed clearly.
4. Fill in the 'Agency or Facility Employer Name' field to indicate where the applicant is employed or will begin employment.
5. Enter the physical address of the agency or facility in the designated space, including the street address, city, state, and zip code.
6. Confirm that your agency is qualified by checking the appropriate status, which includes being a county, state agency, federally recognized Indian tribe, or recognized by the Secretary of Health.
7. Obtain the required signature from the employer or an authorized representative to validate the application.
8. Once all sections are completed, make sure to save changes, download, print, or share the filled-out form as needed.

Complete your documents online today for a smooth credentialing process.