Provider Application Form

Business Legal Name (required)

Doing Business As (DBA), if different than legal name

Contact First Name

Contact Last Name

Street Address

City

State

Zip Code

Mailing Address (if different)

Phone Number

Include Area Code.

Email Address

Fax Number

Include Area Code.

Business Website

Business License Number

Are you a contractor with any other State of Georgia agencies? (required)

If yes, please list the other agency(ies)

Has your business undergone a Financial Audit? (required)

Date of Financial Audit

Are you applying to provide services for the entire state? (required)

If no, please list the counties you are willing to provide services in

Please list below the services you are applying to provide, and the name of the individual who will be providing that service.

Service Category	Employee Providing Service	Operations
Service Category (required)	Employee Providing Service (required)

By signing below, I hereby:

Attest that all information I have provided in conjunction with this provider application is true and complete.
Attest that I am aware of the information set forth in the Provider Manual and expectations associated with providing and maintaining services to GVRA clients
Attest that I will continue to provide true and complete information in conjunction with this application and candidacy for providing client services to which I have applied (“Application Process”), including updates regarding any material changes in circumstances.
Acknowledge and agree that if during the application process, I make any false or misleading statements—including material omission—that this may be considered grounds for elimination for consideration for providing services.

E-Signature (required)

Please type your full legal name to sign.

Date (required)