Community Rehabilitation Program Vendor Application Applicant Information Organization Name: Date: Profit Organization Type: Non-Profit Director: Contact Person: Billing Address: Phone: ( ) Director’s E-mail: Community Rehabilitation Program Services Please mark each service you propose to offer and note the location(s) where it will be available. Supported Employment Services *For CRP vendors who wish to add Project Search, please skip to pg 4 & complete existing approved Project Search Services addendum. Work Adjustment Services Target Population(s): ______________________________________________________________________________ the target population(s). Describe your organization’s experiences with Is each location fully accessible to persons with disabilities? Yes No Address: Phone: Contact E-mail: Person’s Counties Served: VR Unit Office: Contact Person:
Community Rehabilitation Program Vendor Application Applicant Information Organization Name: Date: Organization Type: Profit Non-Profit Director: Contact Person: Billing Address: Phone: ( ) Director’s E-mail: Community Rehabilitation Program Services Please mark each service you propose to offer and note the location(s) where it will be available. Supported Employment Services Project Search Services *For existing approved CRP vendors who wish to add Project Search, please skip to pg 4 & complete addendum. Work Adjustment Services Target Population(s): ______________________________________________________________________________ Describe your organization’s experiences with the target population(s). Is each location fully accessible to persons with disabilities? Yes No Address: Phone: Contact Person’s E-mail: Counties Served: VR Unit Office: Contact Person: