ADP Authorizer Submission Form Are you an ADP Authorizer and want to be listed on our website? No problem! Just complete the form below and watch your information get listed on our maps! ADP Authorizer FormPlease enable JavaScript in your browser to complete this form.Your Name *FirstLastCategory *ADP AuthorizerADP VendorBoth Authorizer and VendorProfession *Occupational TherapistPhysiotherapistNurse PractitionerOphthalmologistOptometristVision Rehabilitation WorkerMassage TherapistSpeech-Language PathologistSpecialist Teacher of the BlindRehabilitation TeacherCCTV Optical Enlargement Systems AuthorizerHigh Technology AuthorizerOrientation and Mobility InstructorDoctorOtolaryngologistAudiologistHearing Instrument PractitionerMembers of Diabetes Education Program (DEP)An amputee team (Physician, a Physiotherapist or Occupational Therapist and a ProsthetistOtherADP Authorizer of: *MobilityHearingCommunication AidsVisual aidsDiabetic Equipment and SuppliesRespiratory Equipment and SuppliesHome Oxygen TherapyArtificial Eyes and Facial ProstheticsGarments, Pumps and BracesBreast Prostheses and Artificial LimbsEnteral Feeding and OstomyName of Business *If not incorporated enter as "Independent Contractor"Business Street AddressIf you wish to have a specific address listed on the map, indicate street address including number.City (this is necessary for geocoding onto map) *This is necessary for geocoding your information onto our map.Postal Code *This is necessary for geocoding your information onto our map.Phone Number (including area code) *This phone number will be displayed on the website so that people can request your services via phone.Email *EmailConfirm EmailThis email will be displayed on the website so that people can request your services via email.Additional InformationEnter other information as needed here. For example, "Ability to drive to client address is an option"MessageSEND MESSAGE