VR3441C Entity Headquarters Information Part C - Texas



Texas Workforce CommissionVocational Rehabilitation ServicesEntity Headquarters Information Part C -Location(s) FORMTEXT ?Instructions: FORMTEXT ?For response to an Electronic State Business Daily (EBSD) posting, follow the instructions in the ESBD posting, FORMTEXT ? otherwise submit updated forms to the Quality Assurance Specialist for VR (Q) or Regional Program Support Specialist (RPSS) and Contract Manager. FORMTEXT ? FORMTEXT ?Follow instructions on the form and in the TWC VR Standards for Providers. FORMTEXT ?Type all information on form using a computer and get all required signatures. FORMTEXT ?Complete all sections of the form. Record “N/A” (not applicable) if a question does not apply. FORMTEXT ? Keep a copy of your submitted form with attachments and supporting documentation for your records. FORMTEXT ?Reason for Submission FORMTEXT ? Date of submission: FORMTEXT ????? FORMCHECKBOX Application packageSolicitation ID: FORMTEXT ????? FORMCHECKBOX Update of information due to change in information on file. For example, qualifications change. FORMCHECKBOX Other: Specify: FORMTEXT ?????Entity’s Information FORMTEXT ? Entity: The business that is requesting or has been granted the bilateral contract with TWC to provide services on behalf of VR customers. FORMTEXT ?Entity’s legal name: FORMTEXT ????? Entity’s “doing business as” (DBA) name: FORMTEXT ?????Provide at least one of the following: FORMTEXT ?Employer Identification Number (EIN) (9 digits, issued by IRS): FORMTEXT ?????Last four digits of the sole proprietor’s Social Security Number: FORMTEXT ?????Counties FORMTEXT ? Select all counties in which the entity can provide services with the staff currently hired. FORMTEXT ?Counties can be added and removed as your staff availability changes without an amendment to the contract. FORMTEXT ?The counties that are added must be listed on the original ESBD posting. FORMTEXT ? FORMCHECKBOX All 254 Texas counties Vocational Rehabilitation Region 1- Borderplex Workforce Development Board FORMTEXT ? FORMCHECKBOX Brewster FORMCHECKBOX El Paso FORMCHECKBOX Hudspeth FORMCHECKBOX Jeff Davis FORMCHECKBOX Presidio FORMCHECKBOX CulbersonVocational Rehabilitation Region 1- Concho Valley Workforce Development Board FORMTEXT ? FORMCHECKBOX Coke FORMCHECKBOX Irion FORMCHECKBOX Mason FORMCHECKBOX Schleicher FORMCHECKBOX Sutton FORMCHECKBOX Concho FORMCHECKBOX Kimble FORMCHECKBOX Menard FORMCHECKBOX Sterling FORMCHECKBOX Tom Green FORMCHECKBOX Crockett FORMCHECKBOX McCulloch FORMCHECKBOX ReaganVocational Rehabilitation Region 1- North Texas Workforce Development Board FORMTEXT ? FORMCHECKBOX Archer FORMCHECKBOX Baylor FORMCHECKBOX Clay FORMCHECKBOX Cottle FORMCHECKBOX Hardeman FORMCHECKBOX Montague FORMCHECKBOX Wilbarger FORMCHECKBOX Foard FORMCHECKBOX Jack FORMCHECKBOX Wichita FORMCHECKBOX YoungVocational Rehabilitation Region 1- Panhandle Workforce Development Board FORMTEXT ? FORMCHECKBOX Armstrong FORMCHECKBOX Dallam FORMCHECKBOX Hartley FORMCHECKBOX Oldham FORMCHECKBOX Swisher FORMCHECKBOX Briscoe FORMCHECKBOX Deaf Smith FORMCHECKBOX Hemphill FORMCHECKBOX Parmer FORMCHECKBOX Wheeler FORMCHECKBOX Carson FORMCHECKBOX Donley FORMCHECKBOX Hutchinson FORMCHECKBOX Potter FORMCHECKBOX Castro FORMCHECKBOX Gray FORMCHECKBOX Lipscomb FORMCHECKBOX Randall FORMCHECKBOX Childress FORMCHECKBOX Hall FORMCHECKBOX Moore FORMCHECKBOX Roberts FORMCHECKBOX Collingsworth FORMCHECKBOX Hansford FORMCHECKBOX Ochiltree FORMCHECKBOX ShermanVocational Rehabilitation Region 1- Permian Basin Workforce Development Board FORMTEXT ? FORMCHECKBOX Andrews FORMCHECKBOX Ector FORMCHECKBOX Loving FORMCHECKBOX Pecos FORMCHECKBOX Upton FORMCHECKBOX Borden FORMCHECKBOX Gaines FORMCHECKBOX Martin FORMCHECKBOX Reeves FORMCHECKBOX Ward FORMCHECKBOX Crane FORMCHECKBOX Glasscock FORMCHECKBOX Midland FORMCHECKBOX Terrell FORMCHECKBOX Winkler FORMCHECKBOX Dawson FORMCHECKBOX HowardVocational Rehabilitation Region 1- South Plains Workforce Development Board FORMTEXT ? FORMCHECKBOX Bailey FORMCHECKBOX Dickens FORMCHECKBOX Hale FORMCHECKBOX Lamb FORMCHECKBOX Motley FORMCHECKBOX Cochran FORMCHECKBOX Floyd FORMCHECKBOX Hockley FORMCHECKBOX Lubbock FORMCHECKBOX Terry FORMCHECKBOX Crosby FORMCHECKBOX Garza FORMCHECKBOX King FORMCHECKBOX Lynn FORMCHECKBOX YoakumVocational Rehabilitation Region 1- West Texas Central Texas Workforce Development Board FORMTEXT ? FORMCHECKBOX Brown FORMCHECKBOX Eastland FORMCHECKBOX Kent FORMCHECKBOX Runnels FORMCHECKBOX Stonewall FORMCHECKBOX Callahan FORMCHECKBOX Fisher FORMCHECKBOX Knox FORMCHECKBOX Scurry FORMCHECKBOX Taylor FORMCHECKBOX Coleman FORMCHECKBOX Haskell FORMCHECKBOX Mitchell FORMCHECKBOX Shackelford FORMCHECKBOX Throckmorton FORMCHECKBOX Comanche FORMCHECKBOX Jones FORMCHECKBOX Nolan FORMCHECKBOX StephensVocational Rehabilitation Region 2- North Central Texas Workforce Development Board FORMTEXT ? FORMCHECKBOX Collin FORMCHECKBOX Erath FORMCHECKBOX Johnson FORMCHECKBOX Palo Pinto FORMCHECKBOX Somervell FORMCHECKBOX Denton FORMCHECKBOX Hood FORMCHECKBOX Kaufman FORMCHECKBOX Parker FORMCHECKBOX Wise FORMCHECKBOX Ellis FORMCHECKBOX Hunt FORMCHECKBOX Navarro FORMCHECKBOX RockwallVocational Rehabilitation Region 2- Tarrant County Workforce Development Board FORMTEXT ? FORMCHECKBOX TarrantVocational Rehabilitation Region 2- Dallas County Workforce Development Board FORMTEXT ? FORMCHECKBOX DallasVocational Rehabilitation Region 2- Texoma Workforce Development Board FORMTEXT ? FORMCHECKBOX Cooke FORMCHECKBOX Fannin FORMCHECKBOX GraysonVocational Rehabilitation Region 3- Heart of Texas Workforce Development Board FORMTEXT ? FORMCHECKBOX Bosque FORMCHECKBOX Freestone FORMCHECKBOX Hill FORMCHECKBOX Limestone FORMCHECKBOX McLennan FORMCHECKBOX FallsVocational Rehabilitation Region 3- Capital Area Workforce Development Board FORMTEXT ? FORMCHECKBOX TravisVocational Rehabilitation Region 3- Rural Capital Area Workforce Development Board FORMTEXT ? FORMCHECKBOX Bastrop FORMCHECKBOX Burnet FORMCHECKBOX Fayette FORMCHECKBOX Lee FORMCHECKBOX Williamson FORMCHECKBOX Blanco FORMCHECKBOX Caldwell FORMCHECKBOX Hays FORMCHECKBOX LlanoVocational Rehabilitation Region 3- Brazos Valley Workforce Development Board FORMTEXT ? FORMCHECKBOX Brazos FORMCHECKBOX Grimes FORMCHECKBOX Madison FORMCHECKBOX Robertson FORMCHECKBOX Washington FORMCHECKBOX Burleson FORMCHECKBOX LeonVocational Rehabilitation Region 3- Central Texas Workforce Development Board FORMTEXT ? FORMCHECKBOX Bell FORMCHECKBOX Hamilton FORMCHECKBOX Milam FORMCHECKBOX Mills FORMCHECKBOX San Saba FORMCHECKBOX Coryell FORMCHECKBOX LampasasVocational Rehabilitation Region 4- Northeast Texas Workforce Development Board FORMTEXT ? FORMCHECKBOX Bowie FORMCHECKBOX Delta FORMCHECKBOX Hopkins FORMCHECKBOX Morris FORMCHECKBOX Titus FORMCHECKBOX Cass FORMCHECKBOX Franklin FORMCHECKBOX Lamar FORMCHECKBOX Red RiverVocational Rehabilitation Region 4- East Texas Workforce Development Board FORMTEXT ? FORMCHECKBOX Anderson FORMCHECKBOX Gregg FORMCHECKBOX Marion FORMCHECKBOX Rusk FORMCHECKBOX Van Zandt FORMCHECKBOX Camp FORMCHECKBOX Harrison FORMCHECKBOX Panola FORMCHECKBOX Smith FORMCHECKBOX Wood FORMCHECKBOX Cherokee FORMCHECKBOX Henderson FORMCHECKBOX Rains FORMCHECKBOX UpshurVocational Rehabilitation Region 4- Deep East Texas Workforce Development Board FORMTEXT ? FORMCHECKBOX Angelina FORMCHECKBOX Nacogdoches FORMCHECKBOX Sabine FORMCHECKBOX San Jacinto FORMCHECKBOX Trinity FORMCHECKBOX Houston FORMCHECKBOX Newton FORMCHECKBOX San Augustine FORMCHECKBOX Shelby FORMCHECKBOX Tyler FORMCHECKBOX Jasper FORMCHECKBOX PolkVocational Rehabilitation Region 4- Southeast Texas Workforce Development Board FORMTEXT ? FORMCHECKBOX Hardin FORMCHECKBOX Jefferson FORMCHECKBOX OrangeVocational Rehabilitation Region 5- Gulf Coast Workforce Development Board FORMTEXT ? FORMCHECKBOX Austin FORMCHECKBOX Colorado FORMCHECKBOX Harris FORMCHECKBOX Montgomery FORMCHECKBOX Waller FORMCHECKBOX Brazoria FORMCHECKBOX Fort Bend FORMCHECKBOX Liberty FORMCHECKBOX Walker FORMCHECKBOX Wharton FORMCHECKBOX Chambers FORMCHECKBOX Galveston FORMCHECKBOX MatagordaVocational Rehabilitation Region 6- Golden Crescent Workforce Development Board FORMTEXT ? FORMCHECKBOX Calhoun FORMCHECKBOX Goliad FORMCHECKBOX Jackson FORMCHECKBOX Lavaca FORMCHECKBOX Victoria FORMCHECKBOX DeWitt FORMCHECKBOX GonzalesVocational Rehabilitation Region 6- Alamo Workforce Development Board FORMTEXT ? FORMCHECKBOX Atascosa FORMCHECKBOX Comal FORMCHECKBOX Guadalupe FORMCHECKBOX Kerr FORMCHECKBOX Medina FORMCHECKBOX Bandera FORMCHECKBOX Frio FORMCHECKBOX Karnes FORMCHECKBOX McMullen FORMCHECKBOX Wilson FORMCHECKBOX Bexar FORMCHECKBOX Gillespie FORMCHECKBOX KendallVocational Rehabilitation Region 6- Lower Rio Grande Valley Workforce Development Board FORMTEXT ? FORMCHECKBOX Hidalgo FORMCHECKBOX Starr FORMCHECKBOX WillacyVocational Rehabilitation Region 6- Cameron County Workforce Development Board FORMTEXT ? FORMCHECKBOX CameronVocational Rehabilitation Region 6- Middle Rio Grande Workforce Development Board FORMTEXT ? FORMCHECKBOX Dimmit FORMCHECKBOX Kinney FORMCHECKBOX Maverick FORMCHECKBOX Uvalde FORMCHECKBOX Zavala FORMCHECKBOX Edwards FORMCHECKBOX La Salle FORMCHECKBOX Real FORMCHECKBOX Val VerdeVocational Rehabilitation Region 6- Coastal Bend Workforce Development Board FORMTEXT ? FORMCHECKBOX Aransas FORMCHECKBOX Duval FORMCHECKBOX Kleberg FORMCHECKBOX Nueces FORMCHECKBOX San Patricio FORMCHECKBOX Bee FORMCHECKBOX Jim Wells FORMCHECKBOX Live Oak FORMCHECKBOX Refugio FORMCHECKBOX Brooks FORMCHECKBOX KenedyVocational Rehabilitation Region 6- South Texas Workforce Development Board FORMTEXT ? FORMCHECKBOX Jim Hogg FORMCHECKBOX Webb FORMCHECKBOX ZapataDescribe 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) FORMTEXT ?????Signatures FORMTEXT ?I, the legally authorized representative, have been named by the entity and have the authority to certify FORMTEXT ?the entity has the ability to provide services in each location(s) identified above FORMTEXT ?the information provided in this form is complete and accurate, and FORMTEXT ?the legal entity is in compliance with all the terms in the Electronic State Business Daily Agency Posting notice, TWC VR Standards for FORMTEXT ? Provider Manual, and/or contract, if awarded. FORMTEXT ? Typed name: FORMTEXT ?????Handwritten Signature:X FORMTEXT ?Date: FORMTEXT ?????Agency Use Only FORMTEXT ?Counties marked above are in the EBSD corresponding to the entity’s application. FORMCHECKBOX Yes FORMCHECKBOX NoComments, if any: FORMTEXT ?????Reviewers of the Form FORMTEXT ?DatePrinted NameTitleInitials FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? ................
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