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Apply to be a Certified application counselor organization

All fields marked with an asterisk (*) are required.

Basic Information
Organization Type

Check all that apply.

How can the Marketplace contact your organization?

999-999-9999

http://www.example.com

Address

A valid Zip code (99999), or Zip+4 (99999-9999)

Points of Contact

Provide the contact information for up to three people that the Marketplace can contact about your organization. Use the "Add another contact" button to add a new contact.

  1. Contact Person

    999-999-9999

How can the general public contact your organization?

You may provide an unlimited number of public locations for your organization.

  1. Public Location

    When this box is checked (default), this location will be shown in the search results on Find Local Help.
    Un-checking this box means that this location will be hidden from the public.

    999-999-9999

    800-999-9999

    999-999-9999

    Address

    When completing the address, include the state or zip code, or both.

    A valid Zip code (99999), or Zip+4 (99999-9999)

    Check this box if you would like to show a comment instead of your address when this location shows up in the search results on Find Local Help. (For example, if a location only provides support over the phone.)

    This comment will be shown in place of your address on Find Local Help.

    Hours of Operation

    You must select "By Appointment Only", or enter the hours of operation for at least one day.

    Indicates that indviduals should schedule appointments before visiting this location. 

    Indicates that this location is open for walk-ins during the specified hours. If you select this option, you will have to provide hours for at least one day of the week. 

    Sunday
    Start Time
    End Time
    Monday
    Start Time
    End Time
    Tuesday
    Start Time
    End Time
    Wednesday
    Start Time
    End Time
    Thursday
    Start Time
    End Time
    Friday
    Start Time
    End Time
    Saturday
    Start Time
    End Time
    Languages

    Select the languages below that your organization supports.

    List any other languages that your organization supports below. Use the "Add another language" button to add additional languages.

Organization details

Do one or all of the following apply to your organization? Answer yes or no for all that apply.

Privacy and Security Experience

Does your organization already:

PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1205. The time required to complete this information collection is estimated to average one hour per application, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact 1-800-318-2596.