Use this form if you are NOT affiliated with an organization

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* 1. Individual or Company Name

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* 2. Contact Person and Title

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* 3. E-mail address

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* 4. Mailing Address

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* 5. Phone Number

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* 6. Indicate the type of services provided (please check all that apply)

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* 7. Individual service providers are required to submit a current state issued ID. Please upload here.

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Individual service providers are required to submit proof of credentials.
Approved credentials include the following:

a. A standard teaching license (Regular or Provisional);
b. Confirmed participation through an Arkansas Department of Education (ADE) approved Alternative Route Program (e.g. ArPep);
c. Meets the requirements established by an accredited tutoring organization;
d. Employed in a teaching or tutoring capacity at an accredited institution of higher education;
e. Graduated with a baccalaureate or graduate degree in the subject area for which tutoring or instructional services are provided;
f. Alternate qualifications related to direct experience in industry or teaching;
g. Active state license to perform therapy services;
h. Current driver's license and proof of insurance (for transportation providers only).

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* 8. Based on your answer to question 6, please upload your required credential documentation.

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* 9. As confirmation of my completion of a background check through the State of Arkansas licensure program, an EFA participating school, or an approved third party, I am uploading a clear copy of those documents.

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* 10. My initials below indicate my understanding that payments using EFA funds are subject to final review and approval by ADE. Any outstanding balance is the financial responsibility of the family receiving services. Payments made to the provider using money outside of the EFA program are to be handled between the family and service provider.

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* 11. My initials below indicate my understanding that eligibility as an education service provider is subject to continuous review by the Arkansas Department of Education and the eligibility process is subject to change with a reasonable amount of notice to the participants.

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* 12. Please provide a description of the services you provide. If you provide instructional services, please provide information on the specific subjects you teach within each category. (e.g. If you teach math, please include the level of math taught - algebra 1 and 2, calculus, etc.).

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* 13. Please describe your experience providing these services.

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* 14. Please upload a copy of your current rate/fee schedule.

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* 15. Please type your full name below to record your signature.

Please ensure all required documentation is submitted with the completed application. Incomplete applications and those submitted without required documentation will be returned to the applicant.

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