Fillable VR Standard Vendor Application

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VR Standard Vendor Application

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Dear Applicant:
Thank you for your interest in becoming a Department of Education, Division of Vocational
Rehabilitation (DOE/DVR) vendor. Please choose from this Standard Vendor Application the vendor type
for which you are seeking registration. You are required to provide proof of applicable requirements and
qualifications as per the VR Vendor Qualifications Manual. In order to be eligible for registration,
potential providers must be authorized by the VR Vendor Registration Unit. Additionally, all potential
providers must first register in MyFlorida Market Place (MFMP) and submit a substitute W-9 to the
Department of Financial Services via the State of Florida Vendor website.
Please read all the instructions included in the application package carefully and complete each item as
requested. Incomplete applications will result in process delays and possible denial. If you have any
questions regarding the application package or process, please contact the Vendor Registration Unit at
866-580-7438 or 850-245-3401 or email at VRVendors@vr.fldoe.org.
Please mail or fax completed applications and all required documentation to:
Division of Vocational Rehabilitation
Vendor Registration Unit
4070 Esplanade Way 2nd Floor
Tallahassee, Florida 32399-7016
Fax Number: 850-245-3394
Thank you for your commitment to helping people with disabilities find and maintain employment and
enhance their independence. We look forward to working with you.
Division of Vocational Rehabilitation
Vendor Registration Unit
Enclosures: VR Standard Vendor Application
ALLISON FLANAGAN
Director, Division of Vocational Rehabilitation
2nd Floor • 4070 Esplanade Way • Tallahassee, FL 32399-7016
Toll Free: 1-800-451-4327 • 850-245-3399 • FAX: 850-245-3392 • www.rehabworks.org
TTY users dial 711 • VP users connect via VRS
VENDOR INFORMATION
MYFLORIDA MARKET PLACE (Federal Tax ID) NUMBER:
* EMPLOYER NAME:
CONTACT PERSON’S NAME:
* MAILING ADDRESS:
City:
State:
Zip Code + Four Digits:
* REMITTANCE ADDRESS:
City:
State:
Zip Code + Four Digits:
PRIMARY TELEPHONE NUMBER:
FAX NUMBER:
CONTACT NAME:
CONTACT PHONE NUMBER:
EMAIL ADDRESS:
* This information should be the same reflected in MFMP and on your registration with the Department
of State, Division of Corporations
2
VR Standard Vendor Application, October 2019
PLEASE LIST LOCATIONS WHERE CUSTOMERS WILL BE SERVED
(Attach additional pages as necessary)
LOCATION 1:
STREET ADDRESS: ____________________________________________________________________________
CITY: ______________________________________ STATE: _____________________ ZIP CODE: _________
LOCATION 2:
STREET ADDRESS: ____________________________________________________________________________
CITY: ______________________________________ STATE: _____________________ ZIP CODE: _________
LOCATION 3:
STREET ADDRESS: ____________________________________________________________________________
CITY: ______________________________________ STATE: _____________________ ZIP CODE: _________
Is each location fully accessible to persons with disabilities? YES ☐ NO ☐
OTHER LANGUAGES
Could you assist customers in other languages? YES ☐ NO ☐
Please mark all applicable:
☐ American Sign Language ☐ Spanish ☐ Creole ☐ Other (Please specify below)
3
VR Standard Vendor Application, October 2019
PLEASE CHOOSE VENDOR TYPE OR TYPES YOU ARE APPLYING FOR:
Department of Health
☐ Audiologist
☐ Mental Health Counselor
☐ Physical Therapists (PT or PT
☐ Certified Nurse Assistant
☐ Nurses – RN or LPN
Assistants)
☐ Dental Laboratory
☐ Occupational Therapists (OT
☐ Physicians
☐ Dentists
or OT Assistant)
☐ Psychologists
☐ Dietician Nutritionist-
☐ Opticians
☐ Respiratory Therapist
Licensed
☐ Optometrists
☐ Social Worker/Marriage and
☐ Hearing Aid Specialist
☐ Orthotist, Prosthetist,
Family Therapists
☐ Message Therapists
Pedorthetist
☐ Pharmacy
☐ Speech-Language Pathologist
Agency for Health Care Administration
☐ Ambulatory Surgical Centers
☐ Clinical Laboratories
☐ Diagnostic Imaging Centers
☐ Health Care Clinic
☐ Home Health Agency
☐ Home/Durable Medical
Equipment
☐ Hospitals
Department of Agriculture
☐ Automobile Repair Shop ☐ Health Studios ☐ Security Officer
School/Training Facility
Department of Children and Family
☐
Behavioral Analyst-Certified
☐
Child Care
Education
☐ Bilingual Interpreters ☐ Commercial Driving
☐ Post-Secondary Schools (Out
☐ Commercial Diving School ☐ Post-Secondary or Adult
of State)
☐ Commercial Boat Operators
Training Courses
Community Ed Public Schools
☐ Post-Secondary Independent
(Private) Schools
☐ Real Estate School
Proprietary
4
VR Standard Vendor Application, October 2019
PLEASE CHOOSE VENDOR TYPE OR TYPES YOU ARE APPLYING FOR (cont.)
Other Goods and Services
Services: Wholesale/Retail Sales and Services
Describe the goods or services you intend to provide to VR Clients:
IS YOUR APPLICATION COMPLETE
☐ Proof of applicable requirements and qualifications, based on the vendor type found in the VR
Vendor Qualifications Manual
☐ List of areas and counties where services will be provided
Please mail, email or fax this application and all required documents to:
Florida Department of Education
Division of Vocational Rehabilitation
Vendor Registration Unit
4070 Esplanade Way, 2
nd
Floor
Tallahassee, Florida 32399-7016
Fax Number: 850-245-3394
Email: VRVendors@vr.fldoe.org
If you have any questions that pertain to this application, please contact the Vendor Registration Unit
at 866-580-7438, or 850-245-3401.
5
VR Standard Vendor Application, October 2019
CONFIDENTIALITY
Access to a VR customer’s confidential information must be safeguarded at all times. Such
information shall not be used or disclosed for any purpose not in conformity with State and Federal
laws and regulations without written consent of the customer or their parent, guardian, or other
authorized representative.
PLEASE READ AND SIGN BELOW
I hereby acknowledge I am authorized to make application on behalf of the Provider to become an
approved DVR Vendor. I further acknowledge that I have read and agree to be bound by the terms of
registration outlined in this application and in section, 413.208, Florida Statutes. I acknowledge that
the Provider is subject at all times to a due-diligence inquiry as to its fitness to undertake service
responsibilities, and that the Provider’s registration may be suspended pending such inquiry. If
approved, we agree to accept and render services to customers of the Division of Vocational
Rehabilitation (VR) on a non-discriminatory basis without regard to race, color, religion, sex, national
origin, age, disability, political affiliation or belief.
Printed Name of Authorized Agent:
Date:
Signature:
6
VR Standard Vendor Application, October 2019
__________________________________________ _______________________________________
DOE/VR AREAS & COUNTIES WHERE SERVICES WILL BE PROVIDED
Vendor Name: FEIN #:
Name of Authorized Representative: ______________________________________________________
Signature: ____________________________________________________________________________
* Check all that apply:
☐ Area One
☐ Area Two
☐ Area Three
☐ Area Four
☐ Area Five
☐
Escambia
☐ Columbia
☐ Lake
☐ Pinellas
☐ Charlotte
Miami-Dade
☐
Santa Rosa
☐ Union
☐ Sumter
☐
Hillsborough
☐ Lee
☐
Okaloosa
☐ Gilchrist
☐ Seminole
☐ Hernando
☐ Collier
☐
Walton
☐ Dixie
☐ Orange
☐ Pasco
☐ Hendry
☐
Holmes
☐ Clay
☐ Osceola
☐ Glades
☐
Jackson
☐ St. Johns
☐ Brevard
☐ Manatee
☐
☐
Washington
☐ Nassau
☐ Polk
☐ Sarasota
☐
☐
Calhoun
☐ Baker
☐ Hardee
☐
Liberty
☐ Putnam
☐ DeSoto
☐
Bay
☐ Duval
☐ Highlands
☐
Gulf
☐ Alachua
☐
Indian River
☐
Franklin
☐ Bradford
☐ St. Lucie
☐
Gadsden
☐ Levy
☐ Martin
☐
Leon
☐ Marion
☐
Okeechobee
☐
Wakulla
☐ Citrus
☐
Jefferson
☐ Flagler
☐
Madison
☐ Volusia
☐
Hamilton
☐
Taylor
☐
Suwanee
☐
Lafayette
7
VR Standard Vendor Application, October 2019
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VR Standard Vendor Application

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Completed 4 October 2021

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