1.

SLRP Provider Application, Part A

·     All sections must be 100% complete and legible. 

·     Please read PART A AND PART B PROVIDER APPLICATION INSTRUCTIONS, found b elow under

SLRP APPLICATION FORMS, as you complete Part A.

In addition, please note that:

SLRP Providers must clearly indicate the type of contract for which they are applying at the top of the first page Part A of their SLRP Provider Application.  They may only apply for one of the following types of contracts:

1.                     Competitive Contract,

2.                    Local Match Contract, or

3.                   CMH/DOC State Match Contract.

 2.

 SLRP Provider Application, Part B

·      All sections must be 100% complete and legible.

·      Get an early start on completing Part B of your Provider Application.

·      Please read PART A AND PART B PROVIDER APPLICATION INSTRUCTIONS, found below

under SLRP APPLICATION FORMS, as you complete Part B.

·      You must include Part B in your Complete, Single-submission Application Package which you must mail to the SLRP Office.

·      Do not instruct your lenders to send their completed Parts B to the SLRP Office.

·      Application forms faxed directly to the SLRP Office will be discarded without notification to the applicant.

·      Read and follow the special instructions for Part B, immediately below.

Special Instructions for Part B:

Please note that Part B of the Provider Application takes considerable time to complete.  First, you must complete Sections l and ll and mail or fax it to the organizations that hold your loans. You must ask them to complete Sections III, IV and V and then mail or fax it back to YOU.  You must the receive the completed Parts B back in time to include them with your Complete, Single-submission SLRP Application Package, which you must mail to the SLRP Office with the required postmark for that application period.  This process can take several weeks, so it makes sense to get an early start on Part B. 

Do not instruct your lenders to send their completed Parts B to the SLRP Office.

It is your responsibility to include completed Parts B in your Complete, Single-submission SLRP Application Package which you must mail to the SLRP Office. 

Please note that you may save a great deal of time by faxing Part B to your lenders and having the lenders fax it back to you.  Previously faxed Parts B are acceptable, as long a they are legible and arrive at the SLRP office by mail as part of your Completed, Single-submission Application Package.  Application forms faxed directly to the SLRP Office will be discarded without notification to the applicant.

 3.

SLRP Practice Site Application & Declaration of Intent:

·         This form is completed and signed by the employer, not by the provider applying for SLRP.

·         You must, however, include an updated SLRP Practice Site Application & Declaration of Intent as part of your Complete, Single-submission SLRP Application Package, even if your employer has previously mailed this form to the SLRP Office on your behalf.

·         All sections must be 100% complete and legible. 

·         If you are applying for a Local Match Contract, make sure your employer has signed in the signature block under Part A- Number 1, indicating a Match Contract Contribution Election. 

The SLRP Practice Site Application & Declaration of Intent serves multiple functions.  In this document, your employer will declare that they intend to employ you throughout the term of your SLRP contract and certify that your Practice Site currently meets all SLR Program requirements. 

If you are a Local Match Contract applicant, your employer must also sign in the Match Contract Contribution Election signature box, to indicate that they are willing to contribute 50% of the amount of your SLRP contract, should your application prove successful.  Only SLRP Provider Applications having a corresponding SLRP Practice Site Application & Declaration of Intent with a clear Match Contract Contribution Election, will be considered as applications for Local Match Contacts.  All Provider Applications lacking this election on its corresponding SLRP Practice Site Application & Declaration of Intent will automatically be considered an application for a Competitive Contract, without notification to the applicant.  

Required Attachments to the SLRP Practice Site Application & Declaration of Intent:

You must make sure that your employer has attached the following documents to the SLRP Practice Site Application & Declaration of Intent.  Any application package lacking these documents will not meet the Complete, Single-submission SLRP Application Package Requirement, and will not be reviewed.

 4.

W9 Tax Form

• All sections must be 100% complete and legible.
• You will find this form on the SLRP Website.

 5.

Payee Registration Form

• All sections must be 100% complete and legible.
• You will find this form on the SLRP Website.