Part 1: Application Cover LetterAgency Legal Name Agency DBA Name Agency EIN Number Agency NPI Number Address (No P.O. Boxes) Address Line 2 City State / Province / Region ZIP / Postal Code Name of Contact/Title PhoneFaxEmail(Required) Website Office Location set up Designated office just for the business listed at the address on this application Running this business from home office Sharing office with someone else/another business Other Please provide answers to the following questions:1. Is your agency Medicare certified? Yes No 2. Has your agency previously been a contracted provider for TSA? Yes No If so, what year? 3. Is your agency able to provide services to all of TSA’s service area (34 communities of southern/western Wayne County)? Yes No If no, what communities are you able to serve?4. How long has your agency been in business? 5. How long has your agency been providing homecare services to clients? 6. Does your agency have a bid agreement with another Area Agency on Aging or Waiver Agency? Yes No If yes, which one(s)?7. How many AAA clients is your agency currently serving? 8. How many private pay clients is your agency currently serving? 9. What is the total number of clients you currently provide service for? 10. Do you have a Registered Nurse (RN) licensed by the State of Michigan on staff? Yes No 11. Do you currently have Certified Nursing Assistants (CNA) employed at your agency? Yes No If yes, how many? 12. Is your agency a staffing company that contracts direct care workers out? Yes No 13. Does your agency W2 all of the direct care workers that are employed at your agency? Yes No 14. How many employees does your agency have? 15. Does your agency keep I9 information on file for all employees? Yes No 16. Does your agency have current insurance (i.e. general liability, worker’s comp, etc)? Yes No 17. Would your agency be willing to purchase additional insurance in order to become a vendor with The Senior Alliance (i.e. cyber liability, third party crime bond, etc) if applicable? Yes No 18. What services can your agency provide? Check all applicable Adult Day Care Chore Services (lawn/snow repairs, deep cleaning, pest control etc.) Community Living Supports Counseling (one visit) Durable Medical Equipment Home Delivered Meals Home Modifications Homemaking PERS Personal Care Private Duty Nursing (PDN/LPN) Residential Services (AFC/HFA licensing required) Respite Care (in-home) Training Transportation Respiratory Therapy If you are interested in providing home modification services, does your agency have a current Builders License? Yes No If you are interested in providing non-emergency transportation services, does your agency have a current Limousine License? Yes No If you are interested in providing non-emergency transportation services, are all agency vehicles properly insured, inspected, and registered with the Michigan Secretary of State? Yes No General Selection and Approval Process for All ApplicantsA. Only complete applications submitted within the established timeframes will be considered for enrollment into the Purchase of Service (POS) vendor pool. The Contracts Manager and/or other Compliance department staff will determine if an application is complete. Requested application documents must be emailed to ewright@thesenioralliance.org. B. Before the application is approved, an introductory meeting may be scheduled with applicable TSA staff. C. Submission of this initial application does not guarantee admission into the vendor pool. Additional documentation may be requested as part of the application process. D. Agreements for new vendors are effective on the date of the Chief Executive Officer’s signature and remain in effect per the terms of the Agreement. E. If an application is approved, the vendor agency will be provided with a POS Agreement to complete and submit for processing. F. Once the applicant agency becomes a POS vendor, TSA staff is provided with relevant bid information. TSA staff will purchase service from vendors on a case-by-case basis, taking into consideration participant preference, staff availability, location, and other relevant factors. G. Applications will be processed and applicants notified of the outcome within 60 days of TSA’s decision and/or receiving a complete application with all supporting documentation. H. Applicants may email contracts@thesenioralliance.org no more than once every 30 days to request an update on the application status. I. Entry into the POS vendor pool does not guarantee that services will be purchased.Consent(Required) I have read the application instructions.(Required)By checking this box and signing below, the applying vendor is confirming that they have read the above application instructions and understand that additional documentation will need to be submitted by the applicant in order for the application to be considered for approval. They are also confirming that all information submitted in this application is accurate and complete.Signature(Required) Δ