Standard Vendor Application - Intake

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

Type of business or service for which you are applying (select all that apply)
Counties to be served (select all that apply)
Is this business classified as private?
Is the business classified as a non-profit?
American Sign Language (ASL) Interpreters, CART Providers
Assistive Technology
Audiologists, Hearing Aid Dispensers, ENT Doctors
Benefits Counseling
Community-Based Work Evaluations (CBWE)
Customized Employment
Functional Capacity Evaluation
Home, Vehicle Modification
Internship Development & Supports
Neurologists
Neuropsychologists
Out-of-School Youth Employment Services (OSYES)
Pre-Employment Transition Services (Pre-ETS)
Psychiatrists
Psychologists
Supported Employment
Traumatic Brain Injury Specialists
Trial Work Experience (TWE)

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.