Application Process for New Providers:
  • The provider will complete all fields in the New Provider Application Information form (see below).
  • HRA will review this information to determine eligibility.
  • If the application is disapproved, HRA will inform the provider the reasons for the disapproval via e-mail.
  • If the application is approved, HRA will provide the new user with an ID and password via e-mail.
  • When ID and password have been received, the provider can return to the system and register their program offerings.

New Provider Application Information
 
              Provider name:
              Provider Federal Tax ID:  (No dash: 123456789)
              Oversight Entity:
              Provider Type:
              State License/Contract/MOU
              Expiration Date: 		 (MM/DD/YYYY)       N/A:
              School Type:
FINANCIAL AID AND STUDENT LOAN INFORMATION
              Federal/State Grant:
              (Check all that apply) 		None:      Pell:      TAP:      Federal Supplemental Educational Opportunity (FSEOG):      Teacher Education Assistance (TEACH):      Iraq and Afghanistan Service:     
Federal Student Aid:     
              Federal/State Loans Default Rate
              as per most recent national cohort: 		N/A:      29% or Below:      30% or Above:     
              Entrance/Exit Counseling:
              (Check all that apply) 		N/A:      By Person:      By Mail:      By E-Mail:      Other:     
PROVIDER ADDRESS
              Address:
              City:      State:       ZIP: 
CONTACT INFORMATION
              Last Name:
              First Name:
              Last 4 digits of SSN:
              Phone Number: (999 999-9999)   Ext:   (optional)
              Fax Number: (999 999-9999)
              E-mail address:  (Example: abcd@efg.org)



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