Transcription of Non-Emergency Transportation Vendor Application
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Non-Emergency Transportation Vendor Application
Page 1 of 5 Non-Emergency Transportation Vendor Application PLEASE CHECK THE FOLLOWING TO MAKE SURE YOU VE SUBMITTED A COMPLETE Application : 1. Have you completed all provider information? 2. Have you attached a copy of your insurance coverage? 3. Have you attached a copy of your business license? 4. Did you sign the Application ? Company Information Legal Name of Service: DBA: Corporate Street Address: City: County: State: Zip Code: Phone: Fax: E-mail: Federal Tax ID Number (or SS# if sole proprietor) Mailing Address: (if different) City: State: Zip Code: If multiple locations, please attach a separate list of all applicable service locations, addresses and contact information 1.
settlements or arbitration proceedings brought against you or currently pending involving you? No 21. Have you (or any employee that will provide services for us) ever been suspended, fined, disciplined, ... pled nolo contrendere to any felony that alleged fraud, an act of violence, child abuse, patient abuse or sexual misconduct or are ...
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