Initial Application Checklist
An application will only be considered complete if each of the necessary items, listed on the Initial Application Checklist, have been included. Please refer to the Initial Application Checklist to avoid delays with your application.
Application for Licensure Forms
New Provider Applications are only being accepted by email.
AGL-02 Application for License (PDF)
AGL-07 Provider Self Certification and Civil Rights Compliance Form (PDF)
Checklists and Other Resources
- Policy: Aging Program Directive 14-20-01 (PDF)
- Attachment 1 – OADLC Request for Waiver Form Template (PDF)
- Attachment 2 – ATF Waiver Attestation Letter Template (PDF)
- Attachment 3 – Unique Chapter 11 Regulations Template (PDF)
- Attachment 4 – Sample QA Review Checklist of Unique Chapter 11 Regulations (PDF)