If you wish to inquire about becoming a service provider,please complete the following information.
Contact Person Full Name:
Contact Person Title:
Type of Service To Be Provided:
Age of Clients To Be Served:
Proposed Service Location:
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:
I have read, comprehend and meet requirements in Title 17 and Title 22 California Code of Regulations, and HRC Service Expectations for the proposed service category.