Corporate/Business Name: Corporate Address: County: Corporate Website: Owner Last Name: Name: Primary Contact: Phone: ( ) - Title: Primary Contact Email: @ Fax: ( ) - Emergency Contact Name: Emergency Contact Home Address: Emergency Contact’s Office Phone: ( ) - Emergency Contact’s Cell Phone: ( ) - @ ( ) - Primary Contact Fax: Trade Name (if different from legal name): Website (if different from Corporate Website): Program Address: County: NPI #: Primary Contact: Phone: ( ) - Title: Primary Contact Email: Fax: ( ) - Hours of Operation Monday Tuesday Wednesday Thursday Friday Saturday Sunday to to to to to to to 2) CORRESPONDENCE ADDRESS INFORMATION: In the event that correspondence must be sent via the United States Postal Service, enter the Correspondence Address to which you want all your correspondence mailed. Please note that, when possible, communications will be sent via email. Corporate Name/Address Trade Name & Address Street Address: City: State: Zip: Preferred Email Address: @ 3) CURRENT CERTIFICATION INFORMATION: A Certification Number” is the registration or certification “Current number issued to the program after the last survey and appears on the program’s Certificate of Approval issued by the Department. Expiration” is the expiration date found on the program’s Certificate of Approval issued by “Certification the Department. Current Certification Number: Certificate Expiration Date: 4) CURRENT CERTIFICATION TYPE: Please check all program and/or service types that the program is currently certified to provide. means the total number of individuals that a program can accommodate. (See COMAR 10.47.02 “Capacity” through 10.47.02.11 & 10.47.03.03 through 10.47.03.07) Capacity
Corporate/Business Name: Corporate Address: County: Corporate Website: Owner Last Name: Name: Primary Contact: Phone: ( ) - Title: Primary Contact Email: @ Fax: ( ) - Emergency Contact Name: Emergency Contact Home Address: Emergency Contact’s Office Phone: ( ) - Emergency Contact’s Cell Phone: ( ) - Primary Contact @ Fax: ( ) - Trade Name (if different from legal name): Website (if different from Corporate Website): Program Address: County: NPI #: Primary Contact: Phone: ( ) - Title: Primary Contact Email: Fax: ( ) - Hours of Operation Monday Tuesday Wednesday Thursday Friday Saturday Sunday to to to to to to to 2) CORRESPONDENCE ADDRESS INFORMATION: In the event that correspondence must be sent via the United States Postal Service, enter the Correspondence Address to which you want all your correspondence mailed. Please note that, when possible, communications will be sent via email. Corporate Name/Address Trade Name & Address Street Address: City: State: Zip: Preferred Email Address: @ 3) CURRENT CERTIFICATION INFORMATION: A “Current Certification Number” is the registration or certification number issued to the program after the last survey and appears on the program’s Certificate of Approval issued by the Department. “Certification Expiration” is the expiration date found on the program’s Certificate of Approval issued by the Department. Current Certification Number: Certificate Expiration Date: 4) CURRENT CERTIFICATION TYPE: Please check all program and/or service types that the program is currently certified to provide. “Capacity” means the total number of individuals that a program can accommodate. (See COMAR 10.47.02 through 10.47.02.11 & 10.47.03.03 through 10.47.03.07) Capacity
COMAR%2010.47%20Application%20-%20REV%207-18-17.docx