Sentri II Add / Remove Staff Form

Add / Remove Staff: *
Provider Name: *
First/Last Name: *
Staff's Program / Team Assignment: *
Phone: *
Supervisor: *
Same account type as
current employee:
Email:
Educational Deg Type:
License Type:
License #:
State License Issued:
License Effective Date:
License Exp Date:

Requested By
First/Last Name: *
Email: *
Phone: *

Does this user require ability to enter claims via Sentri?
Would you like this user to be signed up for claims training?

Please enter the names of any staff that have left your organization. If none type "none".*