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Applicant NameMissing or incorrect value

Name of Governing Body or Management OrganizationMissing or incorrect value

Federal Tax ID or SSN

EIN Missing or incorrect value

EIN or SSN (combined)

SSN

This is a demo form. Please do not enter an actual personal SSN in this form. Using the demo number "078-05-1120" is ok!

Street addressMissing or incorrect value

Street address line 2

Mailing address (combined)

CityMissing or incorrect value

State, territory, or military post Missing or incorrect value

Urbanization

Zip codeMissing or incorrect value

Service address (combined)

Street addressMissing or incorrect value

Street address line 2

CityMissing or incorrect value

State, territory, or military post Missing or incorrect value

Urbanization

Zip codeMissing or incorrect value

Applicant (owner or executive director)Missing or incorrect value

Telephone number Missing or incorrect value

Phone area (readonly)

Phone number (readonly)

Type of Service to be ProvidedMissing or incorrect value

Facility Capacity

Identification of the type of consultants, subcontractors and community resources to be used by the vendor as part of its serviceMissing or incorrect value

I hereby certify to the best of my knowledge and belief, this information is true, correct, and complies with Title 17, Section 54310(a).

Applicant's Signature

Missing or incorrect value

Date Missing or incorrect value

Please read the Department of Developmental Services California Code of Regulations, available from the regional centers, prior to completing this form. Type or print this form. Mail to the regional center serving your area.

Attach applicable information outlined in Title 17, Section 54310(a)(10)

(A) Any license, credential, registration or permit required for the performance of the service or operation of the program, or proof of

application for such document;

(B) Any academic degree required for performance or operation of the service;

(C) Any waiver from licensure, registration, certification, credential, or permit from the responsible controlling agency;

(D) The proposed or existing program design as required in Section 56712 and Section 56762, if applicable, for applicants seeking vendorization as community-based day programs;

(E) The proposed or existing staff qualifications and duty statements as required in Sections 56722 and 56724 for applicants seeking vendorization as community-based day programs;

(F) The proposed or existing design as required in Section 56780 for applicants seeking vendorization as in-home respite services agencies;

(G) The proposed or existing staff qualifications and duty statements as required in Section 56792 for applicants seeking vendorization as in-home respite services agencies;

(H) The signed Home and Community-Based Services Provider Agreement with the Department of Health Services, if required.

Except for the Federal Tax ID or Social Security Number, all information provided by you on this form may be released to a member of the
public pursuant to the Public Records Act, Section 6250 et seq. of the California Government Code.

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Form Builder

Orbeon Demo: Vendor Application

Mailing address

Service address

Certification

Instructions