This form may be completed solely by an executive director or program director (or equivalent) of the agency. Once this form is submitted, an ICA representative will review the request. The request will be reviewed:

to ensure it has been submitted by an executive director or program director (or equivalent),
to ensure that the form appears to have been properly completed,
to determine whether an HMIS license is available (if an additional user is being requested), and
to ensure any other requirements or expectations that may exist have been met.

Submission of this form does not guarantee access to the NDHMIS will be granted, and anyone who will have access to the system must complete the proper training prior to being granted access. If you have any questions, please contact the helpdesk before proceeding.