GOVERNOR TOBY DOUGLAS DIRECTOR Dear Applicant: Thank you for your recent inquiry regarding participa 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your legal name as listed with the IRS in the designated field. Ensure accuracy to avoid processing delays.
3. Provide your business name if it differs from your legal name. If using a fictitious name, include the Fictitious Business Name Statement number.
4. Fill in your business address, including street number, city, and ZIP code. Do not use a P.O. Box for this section.
5. Indicate the enrollment action requested by checking all applicable boxes, such as 'New provider' or 'Change of business address'.
6. Attach required documents like proof of liability insurance and any necessary licenses or certifications as specified in the instructions.
7. Review all entries for completeness and accuracy before submitting. Remember to sign and date the application where indicated.

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