The Cover Letter for Potential Providers for the Division of Developmental Disabilities must be submitted on provider letterhead and must contain the following information about the provider:

  1. Provider's legal name.  If applicable, include the "doing business as" (d.b.a.)  name.
  2. Provider's complete mailing address.  Address must include a street address and, if applicable, a P.O. Box number.
  3. Provider's telephone number, including area code.
  4. Provider's fax number, including area code.
  5. Name, address, telephone number (including extension, if applicable), and e-mail address of the Executive Director.
  6. Name, address, telephone number (including extension, if applicable), and e-mail address of the Board President.
  7. List and describe each service and program that the potential provider desires to provide.
  8. Signature of the Clinical Professional, Executive Director, or Board President.

Please attach the cover letter to the top of the required documents that you will submit to Division of Developmental Disabilities.