Application for Provider Agency Certification Or Re-Certification

California Sex Offender Management Board – CASOMB

Application for Provider Agency Certification or Re-Certification

Every program which wishes to seek or maintain CASOMB approval as a Certified Sex Offender Management Provider Agencyproviding specialized treatment services to registered sex offenders pursuant to Penal Code Sections 290.09, 1203.067 and 3008 must have the agencyrepresentative complete this application. The representative must attest that the provider agency meets the qualifications and complies with standards of practice contained in the currentSex Offender Treatment Provider AgencyCertification Requirements, published by CASOMB and available at The following application should be completed by a representative of the legal entity seeking certification as a “Provider Agency”; whether that entity is an individual independent practitioner, a professional corporation, a not-for-profit corporation, a public agency or an entity constituted through some other legal structure.

Eachagencyproviding designated services must be certified as a provider agencyand each provider working within the agencymust be a CASOMB Certified Provider. Provider certification is a separate process. See

How to complete this application:

Read and understand the Sex Offender Treatment Provider AgencyCertification Requirements before completing this application.

Compiled the relevant records and materials into a Provider Agency Manual which addresses each of the requirements outlined in the current Sex Offender Treatment Provider AgencyCertification Requirements. Actual submission of the verifying documentation is not required as a part of the initial application. However, the documents substantiating that the provider agencymeets the CASOMB requirements may be requested by CASOMB at any time, whether for cause or as part of a random audit. CASOMB expects to be able to review each provider agency’s supporting documentation at some point.

Signan original hard copyand return to the CASOMB office:

CASOMB Certification Unit, 1515 S Street, 212 - North, Sacramento, CA 95811. The provider agencyshould retain a copy of the completed application and attached documentation.

Pay Certification Fee. Checks should be payable to “CASOMB”. All fees are final. There will be no refunds. The fee structure is:

2 year Initial Certification.If Program serves: / 1-10 clients
$90 / 11-40 Clients
$120 / 41+ Clients
$180
2 year Re-Certification. If Program serves: / 1-10 clients
$50 / 11-40 Clients
$65 / 41+ Clients
$100
It is the responsibility of each certified provider agency to notify CASOMB, in writing, of any changes to the program’s name, representative, telephone number, email address, or other key information. If a provider agency changes its address, closes a listed service location or opens a new service location, this information is to be provided to CASOMB as soon as possible and in no case more than thirty days from the time such changes occur. Contact information for CASOMB is found at

12/3/2018 1

Application for Certification or Re-certification
As a Sex Offender Treatment Provider Agency
Complete all parts of this form. Incomplete applications will not be processed. Use “N/A” to indicate information that is not applicable. The information requested will be used to document and evaluate applicant qualifications. Contact CASOMB ( if there are any questions.
Provider Agency Information
Initial Certification Re-Certification
Provider Agency Name:
PrimaryContact:
Email: / Phone:
Clinical Director:
Email: / Phone:
Legal status under which the agency operates:
CHECK ONE / LEGAL STRUCTURE
Sole Proprietorship / License Type & Number:
For-profit Corporation / Corporate ID Number:
Non-profit Corporation / Corporate ID Number:
Public Agency / Managing Agency:
Other (Specify): / Legal ID Number:
I have/will have a Certified SARATSO Scorer for the violence and dynamic risk assessment instruments within 90 days of certification
Primary Legal Address*
Street Address:
City*: / State: / Zip:
Mailing Address(If different)*
Street Address:
City*: / State: / Zip:
Date this form was completed:

* Street Address information of all program sites is retained by CASOMB and not be made public.

List All Locations Where CASOMB RegulatedServices Are Provided

Name of Program or Agency:

Applicant must re-enterthe addresses entered on the previous page if sex offender treatment services will be provided at that address.

Site 1 Clinic Name:
Street Address*:
City, State and Zip Code:
Telephone Number: / County:
Service Language(s):
Site 2 Clinic Name:
Street Address*:
City, State and Zip Code:
Telephone Number: / County:
Service Language(s):
Site 3 Clinic Name:
Street Address*:
City, State and Zip Code:
Telephone Number: / County:
Service Language(s):
Site 4 Clinic Name:
Street Address*:
City, State and Zip Code:
Telephone Number: / County:
Service Language(s):
Site 5 Clinic Name:
Street Address*:
City, State and Zip Code:
Telephone Number: / County:
Service Language(s):

*Street address information is retained by CASOMB and not made public.

All other information will be posted on the CASOMB website.

Any Provider Agency which operates more than 5 separate site locations must submit a list of all locations.

Attestation Form

For Provider Agency Certification or Re-Certification

Provider Agency Name:

I (the undersigned) am a legitimate representative of the above-named provider agency and I am authorized to make the following statements on behalf of that agency.

I attest to the following:

The above-named program has prepared a provider agencymanual that adheres to the CASOMB Provider Agency Certification requirements described in the Sex Offender Treatment Provider Agency Certification Requirements.

All of the statements and materials which describe my program’s components have been prepared and compiled into a manual and that the full manual will be made available to CASOMB staff upon request. CASOMB will not cause these materials to become public documents.

The policies and practices set forth in the manual will be consistently adhered to by the administrator(s) of the provider agency and by each person delivering services in the provider agency.I have/will have a SARATSO Certified Scorer for the SARATSO violence and dynamic risk assessments within 90 days of certification

The Provider Agency will keep the California Sex Offender Management Board informed of any significant changes to the agencyphilosophy or policies or practices and of any changes to the provider agency’s status which substantially change or in any way jeopardize the quality of care rendered. I will notify CASOMB of any changes in the provider agency’s location(s).

I hereby understand that, should I furnish any false or misleading information on this application, such act shall constitute cause for the denial, suspension, or revocation of approval as a Certified Provider Agency by the California Sex Offender Management Board and a civil penalty of up to $1,500, in addition to any other remedy available to CASOMB (Pen. Code, § 9003), and could subject me to an action for a civil penalty brought by a prosecutor on behalf of the people of the State of California.

______Signature Date

Printed Name / Phone
Title or Role / Email

An original signed physical copy of this document and payment must be mailed to CASOMB.

CASOMB, 1515 S Street, 212 – North,Sacramento, CA 95811

California Sex Offender Management Board: Provider Agency Certification or Re-Certification Application

Revised 1/2018