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

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

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.

Captcha

Signature

Date

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Standard Vendor Application - Intake

New Jersey Vocational Rehabilitation Services

Vendor ID and Contact Information

Business Location and Mailing Address

Vendor Business Information

E-Signature