STANDARD VENDOR APPLICATION

The Great Seal of the State of New Jersey

After submitting your electronic application please download the appropriate request for letter of intent located on the DVRS vendor information page.

Please enter the following information

Service Area**: CRP Services Youth Services Both Services
Vendor ID:**: Business Federal Employer Identification, Individual Social Security Number or NJStart ID
Name of Business (as registered):**
Individual's Name:**: Please indicate the name of the individual for whom the application applies.
Location Address:**: (Street)

(Address Line 2)

(City, State, Zip as nnnnn-nnnn or nnnnn)
Mailing Address:**: (Street)

(Address Line 2)

(City, State, Zip as nnnnn-nnnn or nnnnn)
Telephone Number:
Fax Number:
Contact**
Title
Email Address:**: yourname@abc.com
Contact Phone Number:**: (333)333-3333
Type of Business or Service for Which you are Applying:: Supported Employment Medical Services Trial Work Experience (TWE) Training Community based work evaluations ( CBWE) Internships Customized Employment Pre-Employment Transition Services ( PETS) OSYES Other
Please list vendor service type.
If Other Business Type
Year Established:
Number of Employees:**
Counties to be Served:: Atlantic Bergen Burlington Camden Cape May Cumberland Essex Gloucester Hudson Hunterdon Mercer Middlesex Monmouth Morris Ocean Passaic Salem Somerset Sussex Union Warren
Target Population/specialty:
Is Business Classified as Private?: Yes No
Is Business Classified as Non-Profit?**: Yes No
Type of Service:**: New Service Expansion
Professional License/Certificate Number:
Expiration Date:: (MM/DD/YYYY)
(e.g., medical license; real estate license; teacher's certificate)
Please Read and Sign Below:: Checking this box is our agreement that we are signing this form
Signature Name: Enter Name

(** indicates a required field)

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