Town of Ellettsville Form Secure Submission

Download your Town of Ellettsville Provider Option Form HERE

Before you submit your form, please complete the following steps:
o Print clearly and review your form to ensure it is complete.
o Confirm the date of screening is within the following date range: 2/1/2024 - 5/31/2024.
o Be sure to provide a valid email address so we can communicate with you regarding the status of your form.
o Ensure you have signed your form. Your signature is required.

Upload your completed Town of Ellettsville Provider Option Form