State Targeted Response (STR) Opioid Medication Assisted Treatment Company Eligibility Form

  • COMPANY INFORMATION

  • MM slash DD slash YYYY
  • (If “Yes” then Company may submit a proposal in accordance with the posted solicitation.)
    (If “No” then answer Question 2.)
  • (If “Yes” then answer Question 3.)
    (If “No” then Company is not eligible for the STR funding until a license is obtained.)
  • (If “Yes” then Company may submit a proposal in accordance with the posted solicitation.)
    (If “No” then Company is not eligible for the STR funding until registered with SAMHSA.)
  • Max. file size: 256 MB.