Welcome
Provider Account

If you would like to become an approved provider on behalf of the Gardiner Scholarship Program (PLSA), please enter the requested information below.
Our staff will review your submission and provide a response via email with instructions to create your provider account.

indicates a required field.
Group Type
Provider Type:  
Are you part of a group?
Provider Name:  
License #:    
Expiration Date:
Financial Institution Information
Account Type  
Account Usage  
Account Name  
Financial Institution  
State  
City  
ACH Routing Number    
Account Number    
Confirm Account Number    
Provider Contact Information
Physical Street Address:  
State:  
City:  
County:  
Zip Code:  
Do you have a mailing address that is different from your physical address?
 
Primary Contact:  
Primary Contact Email Address:*      
Confirm Email Address:    
Primary Contact Phone Number:    
Provider Tax Information
Tax ID Type:  
Tax ID:    
Do you or your business have family, financial, or business relationships with Step Up For Students staff or board members or do you have a child currently on the Gardiner Scholarship (PLSA)?  
 
 
 

    
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