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EP Program
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EP Certification Provider Information
To apply for EP Certification by Philadelphia Connections, please fill in the following information:
1. Date Application is being filled out: _________________________________
2. Name of person filling out this form: ___________________________________________________
3. Name of Agency: __________________________________________________________________
4. Primary Agency Contact: Staff member who will be primarily responsible for communicating with Connections:
Phone: ____________________________ Email: ___________________________________
5. Backup Agency Contact: Name of backup staff member if primary agency contact person is not
available for any length of time: ________________________________________________________
6. Name of at least one school, university, or other educational institution that has assigned a student, resident, intern, etc. to your agency for the purposes of a field placement, practicum, clinical rotation, internship, etc. School must be involved (or be willing to be involved) in the Philadelphia Connections Enhanced Placement Program:
(Note: faculty or academic programs at the following schools have participated in the Enhanced Placement Program: Bryn Mawr College; Temple University; Widener University; West Chester University; University of Pennsylvania; Rutgers—Camden; Marywood University.
7. Name of the liaison from the school listed above: _________________________________________
For further
information contact: Max Molinaro,
Ph.D. Return to "Providers Page"
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