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New Provider Online Application Form
Instructions: Please Complete the this Online Application Form in Full and Submit. Then Print the PDF Application Form, Complete and Sign, return with all the requested documents, photograph and check amount to Scott Dunbar, DUI Intervention Program, Office of Addictive Diseases, MHDDAD, 2 Peachtree Street, NW, 22-285. Atlanta, Georgia, 30303.
Paper Application to Sign & Send In
Contact Information
First Name:*
Middle Name:
Last Name:*
Mailing Address:*
 
City:*
State:*
Zip Code:*
Phone:*
Phone Ext:
Phone:
Phone Ext:
Phone:
Phone Ext:
Fax:
Email:*
Facility Name:*
Service Type:  
Service Address:*
 
City:*
State:*
Zip Code:*
County:
Region:


Credential/License/Education Information
Credential No 1.*:    Serial No.1:*    Begin Date 1 (mm/dd/yyyy):*    End Date 1(mm/dd/yyyy):*
Credential No 2.:    Serial No.2:    Begin Date 2:    End Date 2:
Credential No 3.:    Serial No.3:    Begin Date 3:    End Date 3:


Facility Contact Information
Contact Person's First Name:*
Contact Person's Last Name:*
Main Phone:*
Main Phone Ext:
Alternate Phone:
Alternate Phone Ext:
Email:*


Registry Information
Minimum Service Fee:*
Maximum Service Fee:*
Languages:
Registry Comments:


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