Please complete the Agency & Employment Information Section below.

(9 digit number)
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(Please use MM/DD/YYYY)
Please select agency from list
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(Please use MM/DD/YYYY)

Supervisor Information

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If you would rather fax this information, you may. A fax version of this form can be found here. FAX the completed form to: PCP-TRIS at (859) 622-6399. For questions, call (859) 622-3462.