2020 mi: Fill out & sign online

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How to use or fill out the Practice Site Application and Declaration of Intent

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Click ‘Get Form’ to open it in the editor.
Begin with the 'Sponsoring Agency Information' section. Fill in the name, federal ID number, address, city, state, zip code, county, and administrator details including their name, title, email, and direct phone number.
Proceed to 'Provider & Agreement Information'. Enter the provider's last name, first name, middle name, title (select from options), discipline/specialty, employment start date or expected start date, and email.
In the 'Practice Site Information' section, confirm if the applicant will work at least 40 hours per week for no less than 45 weeks. Provide details for each practice site listed including name, address, hours per week employed there, and manager contact information.
Complete the 'Certification of Compliance and Declaration of Intent' by reviewing all requirements and signing where indicated. Ensure all information is accurate before submission.

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Versions	Form popularity	Fillable & printable
2021	4.8 Satisfied (39 Votes)
2020	4.1 Satisfied (37 Votes)
2019	4.2 Satisfied (59 Votes)

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