In order for WiCAL to enroll your facility in PEAL and WCCEAL, there are just a few pieces of information necessary to complete your enrollment. Please complete and submit the form below.

Licensee Name: *

The individual or entity that holds the facility license, e.g. Willows Assisted Living, LLC

License Number: *

Doing Business As: *

Facility name

Licensed Bed Capacity: *

Current Occupancy: *

This will be updated with quarterly submissions

Facility Category: *

RCAC
CBRF
AFH

Facility Address: *

County: *

Telephone: *

Contact Person: *

Contact Person Title: *

Contact Email Address: *

PEAL Enrollment Form

WiCAL PEAL Enrollment Form