Community Rehabilitation Program Application Form - Utah State Office Of Rehabilitation Page 4
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12If the facility has a governing body, please list the names of all members:
GOVERNING BODY MEMBERS
Please list all staff members and include their appropriate credentials for their positions.
STAFF MEMBER
CREDENTIALS
I certify that the information contained herein is complete and accurate to the best of my
knowledge, and is furnished for the purpose of obtaining USOR approval to offer services in the
State of Utah, and in conformity with the standards set forth by USOR.
Should circumstances result in any modifications of the content, I will advise the USOR. I
understand that failure to abide by the rules may result in a further review of services that are
provided.
Date
Signature of Chief Executive Officer
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