Personal Emergency Response System (PERS) Providers
Application/Forms

Applications/Forms Complaint Process Contact Us Enforcement Actions Links Open Records Rules/Regulations Statutes/Laws

Click on the links below to print or read the applications/forms.

Registration Application/Renewal Form

• Registration Application/Renewal Form (MS Word Format, 39KB)
• Registration Application/Renewal Form(Adobe Acrobat format, 23KB)

License Application/Renewal Form

• License Application/Renewal Form(MS Word Format, 43KB)
• License Application/Renewal Form(Adobe Acrobat format, 28KB)

Insurance Certificate Form

• Insurance Certificate Form(MS Word Format, 28KB)
• Insurance Certificate Form(Adobe Acrobat format, 17KB)

Branch Office License Application/Renewal Form

• Branch Office License Application/Renewal Form (Word, 34KB)
• Branch Office License Application/Renewal Form (Acrobat format, 20KB)

To access documents in Adobe Acrobat format, you must download the Acrobat Reader software. Please see the DSHS file viewing page for more information and a link to the Adobe website.

Last Updated Febrauary 5, 2007