Become a Provider

Post July 11, 2019

Applicant Information

If you wish to inquire about becoming a service provider,
please complete the following information.

Contact Person Full Name:

Contact Person Title:

Company/Agency Name:

Street Address:

City:

State:

Zip:

Phone Number:

Email address:

Type of Service To Be Provided:

Age of Clients To Be Served:

Proposed Service Location:

Academic Degrees:

Licenses/Credentials:

Are You Currently Vendored With Any Other Regional Center? If Yes, List the Regional Center(s), Program(s), and Vendor Number(s). If No, Enter N/A.:

Are You Now In the Process of Becoming Vendored With Another Regional Center? If Yes, List the Regional Center(s) and Program(s). If No, Enter N/A.:

Have you submitted a previous service provider inquiry to Harbor Regional Center? Yes. No. If yes, when was this inquiry submitted? Enter date or N/A:

Describe experience working with individuals with developmental disabilities:

Describe relevant experience in providing the proposed service:

Other relevant experience:

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