SHARP Employer Contact Update Form/Employer Application Form Part 3
Only complete if you are authorized to make financial and contractual decisions on behalf of employer as the designated SHARP Site Representative. Submit this form as often as needed to keep contact information at your site up-to-date. It is required with the first new employer application.
Name of person filling out this form
*
Email of person filling out this form
*
example@example.com
Employer Name
*
What is the main employer URL (website)?
*
What is the PHYSICAL ADDRESS of the employer's main practice site?
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type of organization
*
Please Select
Non-Profit
For Profit
Government
Is this a Tribal Health Organization?
*
Yes
No
Types of positions for SHARP contracts (Check all that apply)
*
Medical
Behavioral
Dental
Admin
Please complete the required table below for your organization. You will need to keep the link for your submission and update this table as needed or complete a new form if these contacts change.
*
Name
Email
Phone
Site Representative
Accounts Payable
Please complete the table below for your organization. You will need to keep the link for your submission and update this table as needed or complete a new form if these contacts change.
*
Name
Email
Phone
Site Rep Alternate
Chief Executive Officer
Chief Financial Officer
Human Resources Director
Recruiter (if any)
Submit
Should be Empty: