Standard Vendor Application - BC

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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 Location and Mailing Address

Vendor Business Information

Counties to be served (select all that apply)

Benefits Counseling Additional Entity Information

Counties to be served for Benefits Counseling (select all that apply)
Values are not selected
Credential Type

Benefits Counseling New Vendor Questions

List all services that you are providing to NJ DVRS client/consumers. Note: a two-year minimum of service delivery is required for some services, including Vocational Evaluation, Placement, Supported Employment, and Pre-ETS.
County(ies) Entity Currently Serves as NJ Vocational Rehabilitation Services Vendor (check all that apply)

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.