Applicant Information (2)

Contents -

Applicant Information (2)

Complete the details for the applicant on the Applicant page (LI0232) 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.
Date of Birth*
Enter the date of birth using the following format MM/DD/YYYY.
Gender*
Select Female or Male by using the radio button next to the field (

).
EIN/SSN*
Enter either the Employer Identification Number or the Social Security Number for the applicant as appropriate.
Contact Phone Number*
Enter the telephone number for contact in this field using the format ###-###-####.
Home Address*
Enter the first line of the Address in this field.
Address Line 2
Enter the second line of the 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 #####-####.
E-mail Address
Enter the e-mail address for the applicant in this field.

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Submitting RH Applicant Information