a) A provider seeking placement on the approved provider list must complete and submit to the Board an application form provided by the Board that contains the elements prescribed in this Section and identifies the services for which the provider seeks approval. The elements of the application include:

1. 1) provider identification, including name, business address, telephone number, fax number and e-mail address;

3) a listing of any and all currently held licenses or certifications;

1. 4) identification of any languages other than English in which the applicant is fluent and can provide services;
2. 5) the applicant's separate attestations that none of the bars to eligibility listed in Section 1910.50(a)(1)-(5) apply;
3. 6) separate attestations that the applicant meets each of the qualifications applicable to the types of service he or she will provide;
4. 7) an agreement that the applicant will conduct sex offender evaluations and/or provide treatment in accordance with the requirements of this Part.
5. 8) attestation that the applicant's submission of false information will result in removal from the approved provider list; and
6. 9) an agreement to notify the Board immediately if the provider becomes ineligible under Section 1910.50(a)(1)-(5).
7. b) Applicants shall provide certified copies of degrees, licenses, certifications or any other documentation upon request of the application review committee.
8. c) Failure to provide any information requested by the committee, including certified copies of degrees, licenses or certifications, may result in denial of approval or removal from the approved provider list.