Name of Authorized Representative Title of Authorized Representative (Printed) (Printed) APPENDIX A - APPLICATION, ATTACHMENTS, REQUIRED FORMS and SERVICE LEVEL MONITOR ATTACHEMENTS FILE FOLDER 1: Application Document ELECTRONIC FILE Is Document Location NAME Document Required Yes/No Package 2 Application for Enrollment Yes 01-Application Form B Applicant Assumed Name Certificate Yes, if 01.A-DBA Provides applicable. Applicant 01.B-Incorporation Certificate of Incorporation Yes, if Provides applicable. Applicant 01.C-LLC LLC Articles of Formation Yes, if Provides applicable. Applicant 01.D-Partnership Partnership Agreement Yes, if Provides applicable. Yes, if Insurance Acord Document currently Applicant 01.E-Insurance or DFPS Form 4736 insured. Provides Insurance is not required at the time of application. FILE FOLDER 2: Attachments Document ELECTRONIC FILE Is Document Location NAME Document Required Yes/No Applicant 01-License DFPS Residential Yes Provides License or acceptance letter Applicant 02.A-Board Board of Directors Yes, if Provides applicable. Applicant 02.B-Org Chart Professional Organizational Yes Provides Chart
Name of Authorized Representative (Printed) Title of Authorized Representative (Printed) APPENDIX A - APPLICATION, ATTACHMENTS, REQUIRED FORMS and SERVICE LEVEL MONITOR ATTACHEMENTS FILE FOLDER 1: Application Document Location ELECTRONIC FILE NAME Document Is Document Required Yes/No Package 2 Form B 01-Application Application for Enrollment Yes Applicant Provides 01.A-DBA Assumed Name Certificate Yes, if applicable. Applicant Provides 01.B-Incorporation Certificate of Incorporation Yes, if applicable. Applicant Provides 01.C-LLC LLC Articles of Formation Yes, if applicable. Applicant Provides 01.D-Partnership Partnership Agreement Yes, if applicable. Applicant Provides 01.E-Insurance Insurance Acord Document or DFPS Form 4736 Yes, if currently insured. Insurance is not required at the time of application. FILE FOLDER 2: Attachments Document Location ELECTRONIC FILE NAME Document Is Document Required Yes/No Applicant Provides 01-License DFPS Residential License or acceptance letter Yes Applicant Provides 02.A-Board Board of Directors Yes, if applicable. Applicant Provides 02.B-Org Chart Professional Organizational Chart Yes
2-6-1-GRO-Open-Enrollment-Application-Attachments-Required-Forms.docx