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Provider Registration Request
Intake
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Import
Welcome to the Alabama Certification Automation Program
Please submit the form below to request registration within the ACAP platform.
Registration is required for all users.
Once registered, ACAP becomes your one-stop shop from which you may submit, track, and access your various applications, letters, and certifications.
Upon submission, your request will be reviewed and you will receive an email with further instructions.
ℹ️
Complete all required fields in the registration form below to begin using ACAP.
Provider Agency Information
Provider Agency Name
*
Mailing Address
Address line 2
City
*
State
*
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-- Select one --
AK
AL
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CA
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DE
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GA
HI
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IL
IN
KS
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LA
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MI
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NC
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WA
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Zip
*
Personnel Information
Executive Director First Name
*
Executive Director Last Name
*
Executive Director Email
*
Email
form field Executive Director Email
is not in correct form
Phone Number
*
Phone
form field Phone Number
must be in the format: (000) 000-0000
Proxy First Name
Proxy Last Name
Proxy Email
Email
form field Proxy Email
is not in correct form
Proxy Phone Number
Phone
form field Proxy Phone Number
must be in the format: (000) 000-0000
Comments (Optional)
If attaching a file below, please provide a description in addition to any comments.
Attach Supporting Documents (Optional)
Attach any supporting documents that you wish to be reviewed to aid in creation of your profile.
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