Personal Emergency Response System (PERS) Providers Application & Forms

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

Registration Application/Renewal Form

• Registration Application/Renewal Form (MS Word Format, 44 KB)
• Registration Application/Renewal Form(Adobe Acrobat format, 33 KB)

License Application/Renewal Form

• License Application/Renewal Form(MS Word Format, 48 KB)
• License Application/Renewal Form(Adobe Acrobat format, 39 KB)

Insurance Certificate Form

• Insurance Certificate Form(MS Word Format, 32 KB)
• Insurance Certificate Form(Adobe Acrobat format, 22 KB)

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.