Independent Support Broker Application

Individuals interested in becoming a Support Broker must complete and submit this Department approved application. Only those individuals who have successfully completed the Support Broker Training required for any applicant should complete this application. Applicants will be tested and held responsible for knowing the information contained in the training.

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* 1. What is your first name?

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* 2. What is your last name?

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* 3. What is your company name?

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* 4. What is your street address?

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* 5. What is your office phone number?

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* 6. What is your website?

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* 7. At what email address would you like to be contacted?

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* 8. Please select which region(s) you will provide services.

Androscoggin

Aroostook

Cumberland

Franklin

Hancock

Kennebec

Knox

Lincoln

Oxford

Penobscot

Piscataquis

Sagadahoc

Somerset

Waldo

Washington

York

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* 9. What population group are you planning to work with?

Brain Injury

IDD & Autism

Other Related Conditions

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* 10. Are you accepting new clients?

Yes

No

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* 11. Please provide a short description of why you do this work. (400 characters or less)

Support Broker Training: If you have not completed the Independent Support Broker Training Modules, Request a username and password. The 7-part on-demand training is offered in the Open Future Learning Training Platform.

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* 12. Please upload a copy of your Certificate of Completion from Open Futures Learning for Module 1: Self-Direction 101

PDF, DOC, DOCX, PNG, JPG, JPEG file types only.

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* 13. Please upload a copy of your Certificate of Completion from Open Futures Learning for Module 2: Who's Who in Self-Direction?

PDF, DOC, DOCX, PNG, JPG, JPEG file types only.

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* 14. Please upload a copy of your Certificate of Completion from Open Futures Learning for Module 3: Basics of Support Brokerage

PDF, DOC, DOCX, PNG, JPG, JPEG file types only.

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* 15. Please upload a copy of your Certificate of Completion from Open Futures Learning for Module 4: The Self-Direction Workflow: Roles & Responsibilities

PDF, DOC, DOCX, PNG, JPG, JPEG file types only.

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* 16. Please upload a copy of your Certificate of Completion from Open Futures Learning for Module 5: Building Your Self-Direction Toolkit

PDF, DOC, DOCX, PNG, JPG, JPEG file types only.

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* 17. Please upload a copy of your Certificate of Completion from Open Futures Learning for Module 6: Understanding Self-Directed Services in Maine

PDF, DOC, DOCX, PNG, JPG, JPEG file types only.

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* 18. Please upload a copy of your Certificate of Completion from Open Futures Learning for Module 7: The Spend Plan

PDF, DOC, DOCX, PNG, JPG, JPEG file types only.

If you need to process your Criminal Background Check, please use the Maine Criminal History Record and Juvenile Crime Information Request Service. https://apps1.web.maine.gov/online/pcr/

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* 19. Please upload a copy of your Completed Criminal Background Check from the State of Maine.

PDF, DOC, DOCX, PNG, JPG, JPEG file types only.