CDSA. Service Provider Roster Name of Service Provider Agency I certify that this is a complete roster of all employees or subcontractors of my agency who are or will be providing services to infants, toddlers and families enrolled with the N.C. Infant-Toddler Program (N.C. ITP). I further certify that all employees / subcontractors listed below have the requisite current licensure and/or certification and shall maintain such licensure / certification to remain employed or serve as subcontractors for providing services to infants, toddlers and families enrolled in the N.C. ITP. If I employ new staff / subcontractors, I shall submit to the CDSA the additional names and licensure information for new staff / subcontractors along with copies of current licenses/certifications and signed Confidentiality Statement(s) within (2) business days of their employment. Printed Name of CEO or Owner of Service Provider Agency Signature Date of Signature Employee / Subcontractor Name Job Title Indicate Licensure or Certification and Expiration Date (if applicable) Assigned Counties [Printed Name] [Licensure or Certification] [Printed] [Expiration Date] [Printed Name] [Licensure or Certification] [Printed] [Expiration Date] [Printed Name] [Licensure or Certification] [Printed] [Expiration Date] [Printed Name] [Licensure or Certification] [Printed] [Expiration Date] [Printed Name] [Licensure or Certification] [Printed] [Expiration Date] [Printed Name] [Licensure or Certification] [Printed] [Expiration Date] [Printed Name] [Licensure or Certification] [Printed] [Expiration Date]
Appears in 2 contracts
Sources: Provider Agreement, Provider Agreement