Section 1: Applicant Information (page LI0012)

Contents -

Section 1: Applicant Information (page LI0012)

Complete the details for the applicant on the Initial Licensing Visit Request: Section 1 - Applicant Info page (LI0012) as described below.

Application Date

Enter the date which appears on the Initial Licensing Visit Request Application in this field.

Last*, First* and Middle Names and Suffix

Enter the name of the provider in the appropriate name fields.

Gender*

Select Female or Male by using the radio button next to the field ().

Date of Birth*

Enter the date of birth using the following format MM/DD/YYYY.

Mailing Address*

Enter the first line of the Mailing Address in this field.

Mailing Address Line 2

Enter the second line of the Mailing Address in this field.

City

Type the name of the city in this field. If the provider is located outside of Vermont, this is a required field.

Town

Select the name of the town by using the down arrow () next to the field. If the provider is located in Vermont, this is a required field.

State*

The State has been defaulted to Vermont; however if another selection is needed, select the name of the state by using the down arrow () next to the field.

Zip Code*

Enter the zip code in this field using the format #####-####.

Contact Phone*

Enter the telephone number for contact in this field using the format ###-###-####.

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Submitting Section 1 (LP)