Is this a new provider? Yes / No
If yes:
Provider [i.e., business name]:
Site Name(s) [i.e. name(s) used for referrals]:
Please also add the site phone #s, if available
Project: (i.e., SOR or MADOC)
Coordinating Agency(ies) for course:
Service / Course Name [Format: City Course Name]:
Service / Course Description [Name, Weeks, Hours/week]:
Probationary Weeks:
Max WSB Hours:
Maximum Weeks:
Hours per week:
WSB Billing Method: [choose one]
1 - Weekly
2 - After Course Completion
Tuition: $
Tuition Billing Requirement: [either choose one option or a combo of #s 2 and 3]
1 - No Requirement
2 - Existing Attendance Record
3 - Probationary Period Complete