ESBD_516615_1778878985560_Form 09-Entity Headquarters Info-Location(s) (VR 3441C).pdf
PDF 132 KB Posted
- Solicitation number
- 3202600157
- Issued by
- Texas
About this file
This is an Entity Headquarters Information form (Part C - Location(s)) submitted to the Texas Workforce Commission (TWC) Vocational Rehabilitation Services division in response to an Electronic State Business Daily (ESBD) posting. The form is used by entities requesting or holding bilateral contracts with TWC to provide vocational rehabilitation services to VR customers. The document outlines the geographic service areas where the entity can provide services based on currently hired staff availability. Entities may select from all 254 Texas counties organized within six vocational rehabilitation regions and their corresponding workforce development boards, including the Borderplex, Concho Valley, North Texas, Panhandle, Permian Basin, South Plains, West Texas Central Texas, North Central Texas, Tarrant County, Dallas County, Texoma, Heart of Texas, Capital Area, Rural Capital Area, Brazos Valley, Central Texas, Northeast Texas, East Texas, Deep East Texas, Southeast Texas, Gulf Coast, Golden Crescent, Alamo, Lower Rio Grande Valley, Cameron County, Middle Rio Grande, Coastal Bend, and South Texas regions. County selections can be modified as staff availability changes without requiring a contract amendment, provided the counties were listed in the original ESBD posting.
The form requires the legally authorized representative of the entity to certify the accuracy and completeness of submitted information, confirm the entity's ability to provide services in each identified location, and attest to compliance with all terms outlined in the ESBD posting, TWC VR Standards for Provider Manual, and any awarded contract. Entities must provide their legal name, doing business as (DBA) name, and either an Employer Identification Number (EIN) or the last four digits of a sole proprietor's Social Security Number. A description of the specific service area, including any limitations to counties or geographic boundaries within counties, must be included. The form requires typed completion and handwritten signature by the authorized representative, along with submission to the appropriate TWC contact such as the Quality Assurance Specialist for VR or Regional Program Support Specialist, depending on the reason for submission.
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Text version
VR3441C (12/20) Entity Headquarters Information Part C – Location(s) Page 1 of 5
Texas Workforce Commission Vocational Rehabilitation Services
Entity Headquarters Information Part C - Location(s)
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) 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:
Counties
• Select all counties in which the entity can provide services with the staff currently hired.
• Counties can be added and removed as your staff availability changes without an amendment to the contract.
• The counties that are added must be listed on the original ESBD posting.
All 254 Texas counties
Vocational Rehabilitation Region 1- Borderplex Workforce Development Board
Brewster El Paso Hudspeth Jeff Davis Presidio
Culberson
Vocational Rehabilitation Region 1- Concho Valley Workforce Development Board
Coke Irion Mason Schleicher Sutton
Concho Kimble Menard Sterling Tom Green
Crockett McCulloch Reagan
VR3441C (12/20) Entity Headquarters Information Part C – Location(s) Page 2 of 5
Vocational Rehabilitation Region 1- North Texas Workforce Development Board
Archer Baylor Clay
Cottle Hardeman Montague Wilbarger
Foard Jack Wichita Young
Vocational Rehabilitation Region 1- Panhandle Workforce Development Board
Armstrong Dallam Hartley Oldham Swisher
Briscoe Deaf Smith Hemphill Parmer Wheeler
Carson Donley Hutchinson Potter
Castro Gray Lipscomb Randall
Childress Hall Moore Roberts
Collingsworth Hansford Ochiltree Sherman
Vocational Rehabilitation Region 1- Permian Basin Workforce Development Board
Andrews Ector Loving Pecos Upton
Borden Gaines Martin Reeves Ward
Crane Glasscock Midland Terrell Winkler
Dawson Howard
Vocational Rehabilitation Region 1- South Plains Workforce Development Board
Bailey Dickens Hale Lamb Motley
Cochran Floyd Hockley Lubbock Terry
Crosby Garza King Lynn Yoakum
Vocational Rehabilitation Region 1- West Texas Central Texas Workforce Development Board
Brown Eastland Kent Runnels Stonewall
Callahan Fisher Knox Scurry Taylor
Coleman Haskell Mitchell Shackelford Throckmorton
Comanche Jones Nolan Stephens
Vocational Rehabilitation Region 2- North Central Texas Workforce Development Board
Collin Erath Johnson Palo Pinto Somervell
Denton Hood Kaufman Parker Wise
Ellis Hunt Navarro Rockwall
Vocational Rehabilitation Region 2- Tarrant County Workforce Development Board
Tarrant
Vocational Rehabilitation Region 2- Dallas County Workforce Development Board
Dallas
VR3441C (12/20) Entity Headquarters Information Part C – Location(s) Page 3 of 5
Vocational Rehabilitation Region 2- Texoma Workforce Development Board
Cooke Fannin Grayson
Vocational Rehabilitation Region 3- Heart of Texas Workforce Development Board
Bosque Freestone Hill Limestone McLennan
Falls
Vocational Rehabilitation Region 3- Capital Area Workforce Development Board
Travis
Vocational Rehabilitation Region 3- Rural Capital Area Workforce Development Board
Bastrop Burnet Fayette Lee Williamson
Blanco Caldwell Hays Llano
Vocational Rehabilitation Region 3- Brazos Valley Workforce Development Board
Brazos Grimes Madison Robertson Washington
Burleson Leon
Vocational Rehabilitation Region 3- Central Texas Workforce Development Board
Bell Hamilton Milam Mills San Saba
Coryell Lampasas
Vocational Rehabilitation Region 4- Northeast Texas Workforce Development Board
Bowie Delta Hopkins Morris Titus
Cass Franklin Lamar Red River
Vocational Rehabilitation Region 4- East Texas Workforce Development Board
Anderson Gregg Marion Rusk Van Zandt
Camp Harrison Panola Smith Wood
Cherokee Henderson Rains Upshur
Vocational Rehabilitation Region 4- Deep East Texas Workforce Development Board
Angelina Nacogdoches Sabine San Jacinto Trinity
Houston Newton San Augustine Shelby Tyler
Jasper Polk
Vocational Rehabilitation Region 4- Southeast Texas Workforce Development Board
Hardin Jefferson Orange
Vocational Rehabilitation Region 5- Gulf Coast Workforce Development Board
Austin Colorado Harris Montgomery Waller
Brazoria Fort Bend Liberty Walker Wharton
Chambers Galveston Matagorda
VR3441C (12/20) Entity Headquarters Information Part C – Location(s) Page 4 of 5
Vocational Rehabilitation Region 6- Golden Crescent Workforce Development Board
Calhoun Goliad Jackson Lavaca Victoria
DeWitt Gonzales
Vocational Rehabilitation Region 6- Alamo Workforce Development Board
Atascosa Comal Guadalupe Kerr Medina
Bandera Frio Karnes McMullen Wilson
Bexar Gillespie Kendall
Vocational Rehabilitation Region 6- Lower Rio Grande Valley Workforce Development Board
Hidalgo Starr Willacy
Vocational Rehabilitation Region 6- Cameron County Workforce Development Board
Cameron
Vocational Rehabilitation Region 6- Middle Rio Grande Workforce Development Board
Dimmit Kinney Maverick Uvalde Zavala
Edwards La Salle Real Val Verde
Vocational Rehabilitation Region 6- Coastal Bend Workforce Development Board
Aransas Duval Kleberg Nueces San Patricio
Bee Jim Wells Live Oak Refugio
Brooks Kenedy
Vocational Rehabilitation Region 6- South Texas Workforce Development Board
Jim Hogg Webb Zapata
Describe the service area your organization has staff available to provide services, including any limitation to the counties or board listed.
(e.g., Travis county, services are only available within city limits of Austin Texas, or services are available in all counties indicated above)
Signatures I, the legally authorized representative, have been named by the entity and have the authority to certify
• the entity has the ability to provide services in each location(s) identified above
• 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:
VR3441C (12/20) Entity Headquarters Information Part C – Location(s) Page 5 of 5
Agency Use Only Counties marked above are in the EBSD corresponding to the entity’s application. Yes No Comments, if any:
Reviewers of the Form Date Printed Name Title Initials
File details come from the government source that posted it. Updated .