State Targeted Response (STR) Opioid Medication Assisted Treatment Company Eligibility Form COMPANY INFORMATIONCompany name Address Contact Person Telephone number Date business started MM slash DD slash YYYY Question 1. Is Company a Non-Profit in accordance with the Florida Division of Corporations?(If “Yes” then Company may submit a proposal in accordance with the posted solicitation.) (If “No” then answer Question 2.) Yes No Question 2. Is Company currently licensed by the Department of Children and Families for Medication Assisted Treatment?(If “Yes” then answer Question 3.) (If “No” then Company is not eligible for the STR funding until a license is obtained.) Yes No Question 3. Is Company listed on the SAMHSA OTP (Opioid Treatment Program) directory?(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.) Yes No CommentsPlease attach any supporting documents.Max. file size: 256 MB. Δ
