Provider Registration

[Step 1] Contact Information  |  [Step 2] Organization Information  |  [Step 3] Review  |  [Step 4] Completed

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OMB No. 1230-0003

PUBLIC BURDEN STATEMENT
Public reporting burden of this collection of information is estimated to average 15 minutes per response, including time for reviewing instructions, researching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Disability Employment Policy, U.S. Department of Labor, 200 Constitution Avenue, NW, Washington, DC, 20210. Note: The completion of this form is voluntary. Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.

PRIVACY ACT NOTICE
The Office of Disability Employment Policy protects the information collected on this form and holds it confidential in accordance with 42 U.S.C. §1306,5 U.S.C. §552 (Freedom of Information Act), 5 U.S.C. §552a (Privacy Act of 1974), and OMB Circular No. A-130.