GGRC Vendor Checklist Date Company NameContact NameReferred ByType of VendorIf 880SC, Vendor Number for Program/ResidencePhone NumberMailing Address in Service Area Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Association with existing provider (i.e. residential homes/vendor#)If Yes, Tax ID # for Existing providerTax ID # for Potential providerAre you be funded by anyone?YesNoProfit or nonprofit organizationProfitNon-ProfitDoes your company employee their own drivers?YesNoChecklistType of service potential vendor will provideType of vehicles planned to be utilizedUtilizing personal vehicles or company owned Personal Company-Owned How many vehicles are planned to be utilizedVehicles already purchasedYesNoIf applicable, how manyCapacity of vehicle(s)Providing w/c or ambulatory serviceW/CAMBBothArea of service (location where vendor is able to transport individuals)Address where vehicles will be located (dispatch) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contract Signatory Name & TitleContract Signatory Phone NumberContract Signatory E-MailContact for Quality Assurance and Customer Service - Name & TitleContact for Quality Assurance and Customer Service - Phone NumberContact for Quality Assurance and Customer Service - E-MailContact for Billing Department - Name & TitleContact for Billing Department - Phone NumberContact for Billing Department - E-MailIf individuals are lined up for the vendor to transport, are they capable of transporting other individuals other than the ones lined up?YesNoFutureCAPTCHANameThis field is for validation purposes and should be left unchanged.
