Education and Workforce Development Cabinet Office of Vocational Rehabilitation Office for the Blind APPLICATION FORM VENDOR The Office of Vocational Rehabilitation (OVR) and Office for the Blind (OFB) assist Kentuckians with disabilities achieve suitable employment and independence. Thank you for your willingness to collaborate with our agencies in support of that mission. The information below, along with a completed IRS Form W-9, is required to process this application. Failure to provide the required information will delay the acceptance of your application. Business Information Legal Business Name: Doing Business As (DBA) (if applicable) Mailing Address: Payment Information Remittance Address (if different from mailing address) Remittance City County Location: County or Counties where your services are offered (List all counties or attach additional sheets if necessary): Business Contact Information Contact Person (full name and title): Contact Person Telephone Number: Fax: Contact Person Email: Tax Information 9 Digit Taxpayer ID (SSN): Employer ID Number (FEIN): Tax Status (Please Select One) Individual Sole Proprietorship Partnership Estate/Trust Corporation Public Service Corporation Government Non-profit Agency Service Provided (check all that apply) Assistive Technology Hotel/Motel/Lodging Psychologist Attendant Care Housing/Food Reader Business/Trade/Technical School Laboratory Retail/Wholesale Child care License and Permits Supported Employment Chiropractor Medical Clinic Transportation College or University Note taker/Tutor Van Modification Dentist/Oral Surgery On-the-Job Training/Job Coaching Dietary Services Optometrist Electronic Equipment Pharmacy Hospital (In or Out Patient) Property Management Medical Professional (please specify): Therapist (please specify): Interpreter (please specify): not listed (please specify): Certificate/Licensure(as appropriate): Certificate/License Number: Date Certificate/License valid through:
Education and Workforce Development Cabinet Office of Vocational Rehabilitation Office for the Blind VENDOR APPLICATION FORM The Office of Vocational Rehabilitation (OVR) and Office for the Blind (OFB) assist Kentuckians with disabilities achieve suitable employment and independence. Thank you for your willingness to collaborate with our agencies in support of that mission. The information below, along with a completed IRS Form W-9, is required to process this application. Failure to provide the required information will delay the acceptance of your application. Business Information Legal Business Name: Doing Business As (DBA) (if applicable) Mailing Address: Payment Information Remittance Address (if different from mailing address) Remittance City County Location: County or Counties where your services are offered (List all counties or attach additional sheets if necessary): Business Contact Information Contact Person (full name and title): Contact Person Telephone Number: Fax: Contact Person Email: Tax Information 9 Digit Taxpayer ID (SSN): Employer ID Number (FEIN): Tax Status (Please Select One) Individual Sole Proprietorship Partnership Estate/Trust Corporation Public Service Corporation Government Non-profit Agency Service Provided (check all that apply) Assistive Technology Hotel/Motel/Lodging Psychologist Attendant Care Housing/Food Reader Business/Trade/Technical School Laboratory Retail/Wholesale Child care License and Permits Supported Employment Chiropractor Medical Clinic Transportation College or University Note taker/Tutor Van Modification Dentist/Oral Surgery On-the-Job Training/Job Coaching Dietary Services Optometrist Electronic Equipment Pharmacy Hospital (In or Out Patient) Property Management Medical Professional (please specify): Therapist (please specify): Interpreter (please specify): not listed (please specify): Certificate/Licensure(as appropriate): Certificate/License Number: Date Certificate/License valid through:
crpandseapplication.docx