Attestation Statement

All information submitted by me in this application, as well as any attachments or supplemental information, is true, current, and complete to the best of my knowledge and belief as of the date of the signature below. I fully understand that any information provided during the application or recredentialing process is subject to Concern EAP investigation and review. I understand that if any information contained in this application is determined to be false or constitutes a material misstatement, my application may be denied or my affiliate status may be terminated by Concern EAP immediately. I will provide 60 days’ notice prior to termination of partnership with your organization. I further understand that in that event, Concern EAP may be required to submit a report to state licensing authorities. By signing this form, I certify that all of my answer a complete, true, and correct.