Maryland State Department of Education
Division of Rehabilitation Services
DORS Provider/Vendor Application
Please complete the following using the instructions on the next page.
Service provider Vendor
1. Category of Service/Description of commodity(ies)
:
2. P
rovider/Vendor Name:
Name as it appears on vendor invoice, if different:
Telephone: TTY:
Email: Fax:
Websit
e:
3. B
illing Address
:
Ci
ty
: C
ounty:
State: Zip Code:
Telephone: TTY:
Federal IRS Employer Identification Number (EIN)
:
4. A
ppointment Addr
ess
I
f you provide services/goods at more than one office location, list address and telephone num
ber
under
"additional information" or on a separate sheet. All must be accessibl
e.
Location Address:
C
ity, State, Zip
:
T
elephone: TTY
:
Fax:
5. C
ertifications/Licenses/Accreditation (attach copy to application):
State License/Certificate Number
:
E
xpiration Date of License/Certification:
Vendor Number
:
C
heck here if Proprietary/Private School/College:
Attach copy of Maryland Higher
Education Commission or National or Regional Accreditation
6. Area(s) of Practice: (See DORS Provider/Vendor Fact Sheet for contact information)
Western Maryland Southern Maryland Baltimore City Eastern Shore
Central Maryland D.C. Subur
bs B
lind Services only
7. S
pecialty Areas/Additional Informati
on:
Signature & Title of Applicant: Date Signed
The above signature acknowledges that this application does not create an employee-employer relationship
and does not entitle the provider/vendor status of State Personnel. It also confirms that the signatory will abide
by the information included in the Provider/Vendor Fact Sheet
.
Include attachments, as applicable per instructions.
MSDE-DORS-RS-9g:10/19 DORS Provider/Vendor Application Page 1 of 2
T
o obtain this form in Braille, in large print, on disk or in other format, call 1-888-554-0334.
INSTRUCTIONS
Check if applying to be a service provider, vendor, or both.
1. Category of Service/description of commodity/commodities. Indicate category of service, e.g.,
Architectural Modifications Contractor, Audiologist, Dentist, Optometrist, Ophthalmologist,
Neurops
ychologist, Occupational or Physical Therapist, Prosthetist, Psychiatrist, Psychologist, Licensed
Clinical Social Worker, Licensed Clinical Professional Counselor, Speech Therapist, Nurse Practitioner,
Physician's Assistant, Assistive Technology Provider, Benefits Counselor, Tutor, Physician, etc. (Physician
– list medical specialty in Section 7, Specialty Areas/Additional Information.) If vendor of goods, describe
commodities offered. AT Providers, see additional requirements at www.dors.maryland.gov/crps
2. Provider/Vendor. Enter provider/vendor name and contact information. Enter the name as it appears on
vendor invoices, if different.
3. Billing Address. Enter your billing address and billing telephone number. Enter your Federal IRS
Employer I.D. Number. (If you do not have an EIN number, you may use your Social Security Number, but
be aware that it will be included in the State financial system and more available to others than you may
prefer. You can get an EIN number here: https://sa2.www4.irs.gov/modiein/individual/index.jsp
4. Appointment Address(es). For more than one office location, list address and telephone number for
additional location(s) under other information or use separate sheet. All must be accessible.
5. Certification/Licenses/Accreditation – applies to any profession/service that requires certification,
licensure or accreditation to perform applicant’s services.
• Provide a copy of your current State License or Certificate Number. If certified by a professional
organization only (APA, RID), please indicate organization number. Attach copy of License or
Certification. Include expiration date of certificate/license.
• Architectural Modifications Contractors must be licensed by the Maryland Home Improvement
Commission. Forward copies of Maryland Home Improvement Certificate and Certificate of Insurance
(see note under Attachments).
• Tutors, provide copy of teaching certificate or resume and statement from course instructor verifying
your qualifications.
• All career training programs/schools must either be certified by the Maryland Higher Education
Commission or a U.S. Department of Education recognized accreditation agency.
• Foreign language translators must include resume and references from either government or non-profit
organizations for which you have provided translating services in the past.
6. Area(s) of Practice. Check all areas of Maryland where goods and/or services would be provided. See
DORS Provider/Vendor Fact Sheet or www.dors.maryland.gov/crps for regional contact information.
7. Specialty Areas/Additional Information. Specialty areas and additional information should include
Medical specialty and other relevant information (e.g., services for the blind or visually impaired,
psychologist with interpreter skills, languages spoken other than English, etc.). Include if registered as a
Maryland Minority Business Enterprise. AT providers, include device/service.
ATT
ACHMENTS: Applications will be rejected if required documents are not included.
• Internal Revenue Service Form W-9
• For vendors, copy of trader's license/registration to do business in Maryland.
• Copies of licenses, certifications and insurance certificates, if required by governing body.
• MHIC contractors, brief history of the company, & 3 letters of reference from current customers.
•
Literature/brochures describing products and/or services.
Please return application and required information to:
Director, DORS Business Support Services, 2301 Argonne Drive, Baltimore, MD 21218-1696
Phone: 410-554-9415 Fax: 410-554-9413
MSDE-DORS-RS-9g:10/19 DORS Provider/Vendor Application Page 2 of 2
T
o obtain this form in Braille, in large print, on disk or in other format, call 1-888-554-0334.
