17-Form 07-Entity Headquarters Info Management Form (VR 3441A).pdf

VR3441A (03/20) Entity Headquarters Information Part A – Management Team Page 1 of 3

Texas Workforce Commission Vocational Rehabilitation Services

Entity Headquarters Information Part A - Management Team

• For response to an Electronic State Business Daily (EBSD) posting, follow the instructions in the ESBD posting, otherwise submit updated forms to the Quality Assurance Specialist for VR (Q) or Regional Program Support Specialist (RPSS) and Contract Manager.

• Follow instructions on the form and in the TWC VR Standards for Providers.

• Type all information on form using a computer and get all required signatures.

• Complete all sections of the form. Record “N/A” (not applicable) if a question does not apply.

• Keep a copy of your submitted form with attachments and supporting documentation for your records.

Reason for Submission

Date of submission:

Application package Solicitation ID:

Update of information due to change in information on file. For example, qualifications change.

Other. Specify:

Entity’s Information Entity: The business that is requesting or has been granted the bilateral contract with TWC to provide services on behalf of VR customers.

Entity’s legal name:

Entity’s “doing business as” (DBA) name:

Provide at least one of the following:

Employer Identification Number (EIN): (9 digits, issued by IRS):

Last four digits of the sole proprietor’s Social Security Number:

Contract Information: Answer all that apply List any current contracts the entity has with TWC Vocational Rehabilitation:

List any legacy contracts the entity has had with DARS or TWC Vocational Rehabilitation:

No contract related to Vocational Rehabilitation has been granted to this entity.

Entity’s Management Team Legally authorized representative: Person who is authorized to sign contracts and official documents for the entity.

Last name:

First name:

Title:

Phone number:

Alternate phone number:

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Fax number:

Email address:

Billing question contact: The person authorized to make billing decisions for the entity.

N/A. Entity uses the legally authorized representative for billing related questions.

Alternate phone number:

Fax number:

Director: The person appointed by the legally authorized representative as the primary contact for routine TWC communication and is responsible for meeting all TWC VR Standards for Providers manual and contract requirements. If the legally authorized representative is serving as the Entity’s Director, they must complete this section. If there is more than one director, record the lead director. See the TWC VR Standards for Providers manual for more information about requirements for the UNTWISE director credential.

Director’s UNTWISE credential number:

Director’s UNTWISE credential expiration date:

Alternate phone number:

Fax number:

Signatures I, the legally authorized representative, have been named by the entity and have the authority to certify

• the information provided in this form is complete and accurate, and

• the legal entity is in compliance with all the terms in the Electronic State Business Daily Agency posting notice, TWC VR Standards for Provider Manual, and/or contract, if awarded.

Typed name:

Handwritten Signature:

X

Date:

Agency Use Only A VR3455, Provider Staff Information Form, for the director has been submitted or is on file with director credentials verified.

Comments:

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Reviewers of the application:

Date Printed Name Title Initials