Standard Vendor Application - BC

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

Is the business address the same as the mailing address?

Vendor Business Information

Is this business classified as private?
Is the business classified as a non-profit?
Counties to be served (select all that apply)
Benefits Counseling

Benefits Counseling Additional Entity Information

Are you an Employment Network (EN)?
Counties to be served for Benefits Counseling (select all that apply)
Employed by WIPA or affiliated organization?
Credential Type
Credential Status
It is my responsibility to inform DVRS when the agency no longer has the staff to vend services. Conversely, the agency will inform DVRS when they have fully certified staff to resume services.

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.