Section 1905.100  Application

A provider seeking placement on the approved provider list must complete and submit to the Board an application form provided by the Board that contains the elements prescribed in this Section and identifies the services for which the provider seeks approval.  The elements of the application include:

a)         provider identification, including name and business address, telephone number, fax number, and e-mail address;

b)         a listing of the counties in which the applicant provides services;

c)         a listing of any and all currently held licenses or certifications;

d)         identification of any languages other than English in which the applicant is fluent and can provide services (optional);

e)         the applicant's separate attestations that none of the bars to eligibility listed in Section 1905.40 of this Part apply;

f)          separate attestations that the applicant meets each of the qualifications applicable to the types of approval sought;

g)         an agreement that the applicant will conduct sex offender evaluations and provide sex offender treatment in accordance with the requirements of Subpart D of this Part;

h)         attestation that the applicant's submission of false information will result in removal from the approved provider list; and

i)          an agreement to notify the Board immediately if the provider becomes ineligible under Section 1905.40 of this Part.

(Source:  Amended at 29 Ill. Reg. 12273, effective July 25, 2005)