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Agency Name:   
If the applicant has a parent corporation, please provide the following information:
Principal of the Entity:     Title:   
Social Security #:        Phone:    
Email Address:     
If the business is other than a not for profit, please list the name(s) and Social Security Numbers for individuals who own at least 5% interest in the business.  
Name Address Social Security # Percent Email


CRIMINAL CONVICTIONS:  Answers to the following question will be considered for qualification purposes.
Has the Principal of the Entity or the Connecticut Administrator ever been CONVICTED of an offense against criminal or military law, or are there criminal charges currently pending against them?  (exclude minor traffic violations or any offense settled in juvenile court or under a youth offender law).
Principal of the Entity:     Connecticut Administrator:    
If "Yes", please provide a detailed explanation below about the nature of the conviction, degree of rehabilitation and time since release.

Special Note:  You are not required to disclose the existence of any arrest, criminal charge or conviction, the records of which have been erased pursuant to Connecticut General Statutes §46b-146, 54-76o, or 54-142a.  If your criminal records have been erased pursuant to one of these statutes, you may swear under oath that you have never been arrested.  Criminal records that may be erased are records pertaining to a finding of delinquency or that a child was a member of a family with service needs (C.G.S. §46b-146), an adjudication as a youthful offender (C.G.S. §54-76o), a criminal charge that has been dismissed or nolled, a criminal charge for which the person has been found not guilty or a conviction for which the person received an absolute pardon (C.G.S. §54-142a).
I certify that the information regarding criminal convictions and employment history is true and complete to the best of my knowledge and is made in good faith.  I understand the partnership, corporation, association, or governmental agency is subject to disqualification if I knowingly make any misstatement of fact.  All statements made in reference to criminal convictions or employment history in regards to this application are subject to verification as a condition of becoming a qualified provider.
I agree that I will notify the DDS Operation Center immediately in writing if I am arrested or convicted of a crime.
Principal of the Entity For Provider Agency   Title
Date of Birth     Social Security Number   Date
Connecticut Administrator For Provider Agency   Title  
Date of Birth Social Security Number Date
Name of Person Submitting Application*     Title  

* Electronic signature: By signing this document, I attest this is my electronic signature. I hereby certify that I am authorized to submit these documents on behalf of the organization.


E-mail Address for submission confirmation:    

Confirm Email for submission confirmation: