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NA/MA Education Site Application

Enter the business name of the education site in the Name field.
Enter the physical address of the education site in the Address field.
Enter the name of the training program requesting approval in the Program Name field.
Select the desired education site from the Education Site Name- Select from List field drop-down menu. If you are unable to find the site here, leave i t blank and continue below.
IF YOU DID NOT FIND THE SITE IN THE DROP-DOWN MENU: Add it here in the Education Site Name- Write In field. Type in the business name and physical address of the site.

Name

Address

City

State

Zipcode

Education Site / Program Information

Program Name

Education Site Name - Select from list If you cannot find the site name you are looking for in the drop-down menu, please fill out the Education Site Name Write in section below.

Education Site Name - Write in Please check the drop-down menu above for the education site you are looking for before filling in this section

What will <your program> be using the site as?

What type of facility is this?

Facility type other: Write in Specify what type of facility here if other is selected

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Waiver of Prohibition If the site you are applying for is on prohibition, but has received a waiver to host NA cohorts, please attach the official waiver letter to this application.

Affidavit

I hereby verify that I understand and agree with the statements contained herein and the above information is true and correct.

By Submitting

I hereby verify that I understand and agree with the statements contained herein and the above information is true and correct.

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