A navigator shall submit a complete application to the Office via email or fax. A complete CMN Program application shall include: A completed application form provided by the Office that is signed and dated by a navigator or the applicant; A completed certification of serious illness or need for life support equipment form that shall include, at a minimum, the following: A certification of a serious illness or the need for life-support equipment made by: A licensed physician; or A certified nurse practitioner; The name and address of the seriously ill person; A statement that the seriously ill person or person in need of life-support equipment is the applicant or an occupant of the premises in which the applicant resides; The name, address, telephone number, physician or certified nurse practitioner license number, and signature of the certifying physician or certified nurse practitioner; and A statement that termination of electric, gas, or other energy source service will aggravate a serious illness or prevent the use of life-support equipment; A completed application form as defined in COMAR 07.03.22.05; and A termination notice issued by a fuel vendor or utility vendor.