New Jersey Vocational Rehabilitation Services

Standard Vendor Application

Please complete this application if you wish to provide vendor services for the New Jersey Department of Labor and Workforce Development, Division of Vocational Rehabilitation Services (DVRS).

To obtain your UEI (Unique Entity Identifier) number, visit sam.gov. To obtain your NJStart number, visit njstart.gov.

Note: any question with an " * " is required to be completed.

Vendor ID and Contact Information

Business Name (as registered)

Business Email

Business Telephone Number

Business Fax Number

Unique Entity Identifier (UEI, Formerly DUNS number)

NJStart ID (should start with a capital "V" followed by 8 numbers - this field is case sensitive)

Contact First Name

Contact Last Name

Title

Contact Email Address

Contact Phone Number

Business Location and Mailing Address

Business Street Address

Business Suite/Floor Number

City

County

State

Zip Code

Is the business address the same as the mailing address?

Yes

Mailing Address

Mailing Suite/Floor Number

Mailing City

Mailing County

Mailing State

Mailing Zip Code

Vendor Business Information

Business Name

Year established

Number of Employees

Type of business or service for which you are applying (select all that apply)

Community-Based Work Evaluations (CBWE)

Customized Employment

Internship Development & Supports

Supported Employment

Trial Work Experience (TWE)

Target population/specialty

Is this business classified as private?

Yes

Is the business classified as a non-profit?

Yes

Supported Employment

New Vendor

Expanding Vendor

Expanding Counties

Are you already a vendor for Supported Employment with NJDOL DVRS?

Yes

You must be a Supported Employment Vendor with NJDOL DRVS before applying to become a vendor for CBWE, Customized Employment, Internship, or TWE. Applying to these services without being an existing Supported Employment vendor will result in your application being denied.

Supported Employment Expanding Counties

Are you a current Supported Employment/Long-Term Follow-Along provider for DDD?

Yes

Provide an explanation of existing relationships with external organizations and agencies.

Please provide written documentation showing need for the service where you wish to vend?

Provide statistics for the last 3 years.

Number of referrals (Year 1)

Number of referrals (Year 2)

Number of referrals (Year 3)

Number of individuals in Pre-Placement (Year 1)

Number of individuals in Pre-Placement (Year 2)

Number of individuals in Pre-Placement (Year 3)

Number of Placements (Year 1)

Number of Placements (Year 2)

Number of Placements (Year 3)

Number of individuals who have maintained employment for over 90 days (Year 1)

Number of individuals who have maintained employment for over 90 days (Year 2)

Number of individuals who have maintained employment for over 90 days (Year 3)

Number of Long-Term Follow-Along (LTFA) participants (Year 1)

Number of Long-Term Follow-Along (LTFA) participants (Year 2)

Number of Long-Term Follow-Along (LTFA) participants (Year 3)

Number of person(s) transitioned off of LTFA (Year 1)

Number of person(s) transitioned off of LTFA (Year 2)

Number of person(s) transitioned off of LTFA (Year 3)

Organizational Chart

Do you have a minimum of two full time job coaches?

Yes

Name

Job Title

Counties Values are not selected

Trainings Attended

Community Based Work Evaluation

Trial Work Experience

Internship Development and Supports

Customized Employment

Supported Employment and Long-Term Follow-Along

Bogg's Center 4 Part Employment

Specialist Services

Other Trainings Attended

Languages Spoken

Full Time/Part Time

Years of Service

Resume

Provide your organization's Mission Statement.

Proof of appropriate national accreditation to vend employment support services (e.g. CARF)

If you do not currently have such accreditation, you will be required to obtain the accreditation within 3 years of your application to become a DVRS vendor.

I understand

List the specific services you are providing in each county that you serve.

Exisiting Vendor Additional Questions

Provide a rationale for the expansion of services or addition of new services. Include information as to your ability to manage the addition or expansion of services.

New Supported Employment Vendor Questions

Does your organization complete financial audits by an independent auditor annually?

Yes

Provide the date of the last audit.

Provide proof of the last audit report. (i.e. an email, first page of the PDF, etc.)

As a non-profit you must complete financial audits in order to be considered. By selecting "No" your application will be denied.

Does your organization have liability insurance/coverage?

Yes

Provide proof of coverage.

If you do not have Liability Insurance your application will be denied.

Has your organization been providing the service you are applying for for at least 2 years or are you able to demonstrate the capacity to provide this service?

Yes

Provide a basic business plan for service implementation and continuance.

Provide a copy of the procedure that identifies an alternate job coach when the assigned coach is not available

Do you have additional funding sources besides DVRS to support salaries?

Yes

Provide current funding sources and amounts received.

Does your organization belong to any of the following? (Select all that apply)

New Jersey Association of People Supporting Employment First (NJ APSE)

Association of People Supporting Employment First (APSE)

Accses NJ

National Rehabilitation Association (NRA)

Other

Other Organization you are a part of

Provide a history of your organization.

Do you provide services to the NJ Division of Developmental Disabilities (DDD)?

Yes

Please indicate the service(s) that are offered to the NJ DDD. If you provide Supported Employment or Long Term Follow Along indicate that here.

Do you have a valid location/address that meets ADA standards?

Yes

How do you store consumer records?

Supported Employment and Classified as a Non Profit

Do you have a governing board?

Yes

How many board members do you have

Please provide a copy of proof of tax exemption under section 501©3 of IRS Code 3.2 Governing Entity

Name

Their Background

Name

Their Background

Name

Their Background

Name

Their Background

Name

Their Background

Name

Their Background

Name

Their Background

Has there been a board meeting in the last 6 months?

Yes

Please provide a copy of the most recent board meeting minutes to confirm that the meeting occurred.

CBWE Questions

Employer Name

Job Titles

Town

County Value is not selected

Employer Name

Job Titles

Town

County Value is not selected

Employer Name

Job Titles

Town

County Value is not selected

Does your organization have liability insurance/coverage?

Yes

Provide proof of coverage.

If you do not have Liability Insurance your application will be denied.

Proof of attendance of training with DVRS CRP staff for each staff member

List of assessments to be used for the Intake/Assessment phase

Customized Employment Services Questions

Proof of ACRE or related certification for each staff member (i.e. Marc Gold & Associates)

Proof of attendance of training with DVRS CRP staff for each staff member

Does your organization have liability insurance/coverage?

Yes

Provide proof of coverage.

If you do not have Liability Insurance your application will be denied.

Internship Development & Supports Questions

Provide a review of direct or related experience in working with individuals who have participated in internships.

Does your organization have liability insurance/coverage?

Yes

Provide proof of coverage.

If you do not have Liability Insurance your application will be denied.

Proof of attendance of meeting/training with DVRS CRP staff for each staff member

Trial Work Experience Questions

Employer Name

Job Titles

Town

County Value is not selected

Employer Name

Job Titles

Town

County Value is not selected

Does your organization have liability insurance/coverage?

Yes

Provide proof of coverage.

If you do not have Liability Insurance your application will be denied.

Proof of completition of appropriate training with DVRS CRP staff for each staff member

E-Signature

By signing below, I am electronically signing this application and verifying that the information submitted is correct. This electronic signature has the same legal effect as a written signature.

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Signature

Date

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Standard Vendor Application - CRP

New Jersey Vocational Rehabilitation Services

Vendor ID and Contact Information

Business Location and Mailing Address

Vendor Business Information

Supported Employment Expanding Counties

Exisiting Vendor Additional Questions

New Supported Employment Vendor Questions

Supported Employment and Classified as a Non Profit

CBWE Questions

Customized Employment Services Questions

Internship Development & Supports Questions

Trial Work Experience Questions

E-Signature