LICENSE EXEMPT PROVIDER REGISTRATION CHECKLIST
To complete the registration process, please send the following items within 10 business days to:
City, State, Zip
- PICTURE IDENTIFICATION (Copy of front and back)
Any one of the following will be accepted:
- Current Driver License
- Current State ID
- Current Military ID
- SOCIAL SECURITY CARD (Copy)
If your social security card has been lost or stolen, you may obtain a duplicate card from the Social Security Administration. This service is free. You must complete an Application for a Social Security Card. Form SS-5 may be obtained by calling
1-800-772-1213 or by visiting any local Social Security office. Form SS-5 is also available for download at: http://www.socialsecurity.gov/online/ss-5.html.
- W-9 Form (Original)
Complete and sign the form.