ESBD_515780_1778790544008_Form 10-Entity’s Physical Location(s) Part A (VR 3442A).pdf
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- Solicitation number
- 3202600156
- Issued by
- Texas
About this file
This is a certification form (VR3442A) issued by the Texas Workforce Commission Vocational Rehabilitation Services for entities seeking to establish or update their physical location information as part of service contract applications. The form serves as a foundational document for contractors applying to provide vocational rehabilitation services to VR customers through bilateral contracts with TWC. The form requires entities to provide their legal business name, doing business as (DBA) name, and either an Employer Identification Number or the last four digits of a sole proprietor's Social Security Number. Entities must certify whether they maintain one or more dedicated physical locations that are owned, leased, or otherwise controlled by the contractor for service delivery or customer meetings, excluding community sites such as state, federal, city, or county public meeting spaces. If an entity operates exclusively at community sites not owned or leased by the contractor, no physical location certification is required.
The form requires completion by a legally authorized representative who must provide a typed name, handwritten signature, and submission date. Entities submitting the form must indicate the reason for submission, whether responding to an Electronic State Business Daily posting, updating information due to changes in physical location, or for other specified reasons. The form mandates that contractors maintain a copy of the completed submission along with all attachments and supporting documentation for their records. If the entity maintains physical locations, a separate VR3442B form must be completed for each location. The form includes a certification statement whereby the authorized representative attests that all information provided is true and accurate and acknowledges the obligation to update the form whenever information changes.
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Text version
VR3442A (12/22) Entity’s Physical Location Part A – Service Contracts Certification Statement Page 1 of 1
Texas Workforce Commission Vocational Rehabilitation Services
Entity’s Physical Location(s) Part A – Service Contracts Certification Statement
Instructions:
• 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).
• 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: Solicitation ID: or Contract #:
Application package
Update of information due to change in information on file. For example, new physical location.
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:
Certification of Entity’s Physical Location Status Physical location: Is a location the contractor owns, leases, or uses as dedicated space to provide goods and/or services to customers and/or attend meetings with customers.
NOTE: Physical locations do not include community sites such as state, federal, city, county, or other public meeting spaces. Contactors that provide all services at community sites that are not owned or leased by the contractor are not required to maintain a physical location.
The entity has one or more physical locations as defined above. Yes No
If yes, a VR3442B MUST be completed for each location.
I, the legally authorized representative, have the authority to certify:
• all inforamtion on this form is true and accurate; and
• the entity acknowledges it must update this form anytime information changes.
Typed name:
Handwritten Signature:
X
Date:
File details come from the government source that posted it. Updated .