05.02.02-Provider Registration Checklist

LICENSE EXEMPT PROVIDER REGISTRATION CHECKLIST

To complete the registration process, please send the following items within 10 business days to:

CCR&R Name
CCR&R Address
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.