Illinois SES Provider Application and Annual Reporting
Create New Provider
USERNAME (3-12 characters)
*
PASSWORD
*
REENTER PASSWORD
*
CORPORATE NAME
*
FEIN
*
NAME COMMONLY USED FOR SES DELIVERY (if different)
ORGANIZATION TYPE (choose one)
*
For Profit
Nonprofit
Institution of Higher Learning
Local Education Agency (LEA)
School
Other Governmental Entity
ADDRESS OF PRINCIPAL OFFICE - STREET ADDRESS
*
CITY
*
STATE
*
ZIP CODE
*
LOCAL ADDRESS OF PRINCIPAL OFFICE (if different) - STREET ADDRESS
TELEPHONE NUMBER (include area code)
*
CITY
STATE
ZIP CODE
FAX NUMBER (include area code)
EMAIL ADDRESS
*
WEBSITE
ADMINISTRATIVE HOURS
-
?
ONLINE PROVIDER
*
Yes
No