OCFS-3598 (Rev. 10/2013)

NEW YORK STATE

OFFICE OF CHILDREN AND FAMILY SERVICES

Commission for the Blind

INDIVIDUAL PRIVATE VENDOR APPLICATION

 

DISTRICT OFFICE USE

PERSONAL

AVAILABILITY

ASSISTIVE TECHNOLOGY COMPETENCIES

ATTACHED (Please Check)

Have you ever been convicted of a crime or forfeited collateral or are you now under charges for any crime in New York State or any other jurisdiction?

Have you ever been or are you currently the subject of an indicated child abuse or maltreatment report on file with the New York Statewide Central Register of Child Abuse and Maltreatment?

Have you ever been or are you currently the subject of an indicated child abuse or maltreatment report on file with the New York State Justice Center for the Protection of People with Special Needs?

CERTIFICATION

NYSCB OFFICE USE

VENDOR APPROVED

DATE: