APPLICATION CHECKLIST Use this checklist to insure that your application is complete and submit items to: PREFERRED METHOD OF SUBMISSION IS ELECTRONIC VIA EMAIL P.A.C.E. ® Coordinator 347 Ypsilanti St., Dundee, MI PH: 571-748-3776 Fax: 734-310-6880 Email: Completed and signed Application for Provider Status. (A3) Curriculum Vitae (CV) or Resume of Program Administrator (Annual Providers only) Provider Invoice Request Form (A4) Sample of program brochure/flyer (See requirements in section 2.12 of the P.A.C.E.® manual Program/speaker information form for each program (Note: this is optional if the information on this form is already included in the brochure/flyer.) (A5) Example of the roster to be used (A8 or equivalent) Program Evaluation Form for participant to evaluate the program (only 1 version of A9 or equivalent needed) Example of the certificate of completion/attendance to be used (A11) A2 APPLICATION FOR PROVIDER STATUS
APPLICATION CHECKLIST Use this checklist to insure that your application is complete and submit items to: PREFERRED METHOD OF SUBMISSION IS ELECTRONIC VIA EMAIL P.A.C.E. ® Coordinator 347 Ypsilanti St., Dundee, MI PH: 571-748-3776 Fax: 734-310-6880 Email: Completed and signed Application for Provider Status. (A3) Curriculum Vitae (CV) or Resume of Program Administrator (Annual Providers only) Provider Invoice Request Form (A4) Sample of program brochure/flyer (See requirements in section 2.12 of the P.A.C.E.® manual Program/speaker information form for each program (Note: this is optional if the information on this form is already included in the brochure/flyer.) (A5) Example of the roster to be used (A8 or equivalent) Program Evaluation Form for participant to evaluate the program (only 1 version of A9 or equivalent needed) Example of the certificate of completion/attendance to be used (A11) A2 APPLICATION FOR PROVIDER STATUS
Application_rev2018.docx