Technical Assistance Request Form
Thank you for taking the time to complete this request. A Training & Technical Assistance Specialist will contact you to assess your programs needs and answer any questions you may have.
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Email *
Name (first, last): *
Street Address: *
City: *
ZIp Code: *
Telephone Number: *
Fax Number:
Child Care Program name (if applicable):
Current License Status (check all that apply): *
In what areas do you need technical assistance (check all that apply): *
Is this facility currently under investigation or active Administrative Action? *
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