Form Ddd-1821a Forff - Qualified Vendor Ready To Provide Services
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1ARIZONA DEPARTMENT OF ECONOMIC SECURITY
DDD-1821A FORFF(4-17)
Division of Developmental Disabilities
QUALIFIED VENDOR READY TO PROVIDE SERVICES
PERSONAL INFORMATION
QV NAME
QV ID # (FEI)
LINGUISTIC CAPABILITIES (Include all Languages)
ADDRESS
CITY
STATE
ZIP CODE
PHONE NUMBER
EMAIL
FAX
CONTACT
VENDOR CALL EMAIL
WEBSITE
EFFECTIVE DATE
SERVICES PROVIDED BY QVA (List New)
(Therapy Only):
Center Based
Home Based
BRIEF DESCRIPTION OF QUALIFIED VENDOR AGENCY
BRIEF DESCRIPTION OF CULTURAL CAPABILITIES
District(s) Served
East
Central
West
North
South
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with
Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the Genetic
Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in admissions, programs, services, activities,
or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. To request this document in
alternative format or for further information about this policy, contact the Division of Developmental Disabilities ADA Coordinator at 602-
542-0419; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon request. Disponible en español en
línea o en la oficina local.
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