DOE Form VPK-SIS1 This form must be filled out completely, including original signature on last page. Appropriate and complete documentation (see section B. below), must accompany this form. A. Contact information
Name of agency head: Click here to enter text.
Name of Contact Person: Click here to enter text. Title: Click here to enter text.
Mailing Address: Click here to enter text.
City: Click here to enter text. State: Click here to enter text. Zip Code: Click here to enter text.
Telephone Number: Click here to enter text. Fax Number: Click here to enter text.
Email address: Click here to enter text. Organization Website: Click here to enter text. B. Service Provided
Please check the appropriate box below and attach documentation of the applicable credential to this form for processing.
Listening and Spoken Language Specialist™ certified by the Alexander Graham Bell Academy for Listening and Spoken Language
Board Certified Behavior Analyst certified by the Behavior Analyst Certification Board® pursuant to Rule 65G-4.0011, F.A.C.
C. Applicant Information
Check the category(ies) that best describes the applicant’s organization:
Small group (group size two to five students per provider)
Large group (group size six to ten students per provider)
Ability to communicate languages other than English
Other (identify): Click here to enter text.
Times offered:Click here to enter text. E. County/Counties to be Served Baker
I, THE UNDERSIGNED, CERTIFYthat all of the information provided herein is true and accurate, to the best of my knowledge. In the instance that I am signing on behalf of an organization, I am authorized to act on behalf of the organization.
_____________________________________ Click here to enter text.