Application for Registration – Invoiced Application for Registration INVOICED Today's Date* MM slash DD slash YYYY Please explain why you would like to be a NRRTS Registrant.*I understand that as a NRRTS Registrant I will receive periodic, non-marketing digital notifications directly from NRRTS.* Yes Gender (Optional) Male Female Year You Were Born (YEAR ONLY)*Will be used for NRRTS purposes onlyName* First Last Goes by*Preferred Mailing Address* Company Home Company Name*Company Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Company Phone*Company website*Home Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Mobile Phone*Primary Email - NRRTS will use for communication with you* Recovery Email* Do you have the RESNA ATP?*ATP is not required to become a NRRTS Registrant. Yes No RESNA ATP Expiration Date MM slash DD slash YYYY Do you have the RESNA SMS?* Yes No I have read and understand the NRRTS Registrant requirements.* Yes, I have read the NRRTS Registrant requirements. No, I have not read the NRRTS Registrant requirements. I participate in the clinical evaluation of Complex Rehab Technology (CRT).* Yes No I offer recommendations of CRT at the evaluation* Yes No I participate in fitting/delivery of prescribed systems* Yes No EMPLOYMENT EXPERIENCENOTE: To be considered, the applicant must have at least one year experience as a Rehabilitation Technology Supplier.1. Total number years employed as Rehabilitation Technology Supplier*1a. Do you have supervisory or management responsibility?* Yes No 1b. What percentage of your time is spent on direct patient care, service delivery and fitting?*1c. Provide a brief description of your practice in regard to patient care, service delivery and fitting.* Include your areas of specialization0 of 300 max charactersPRACTICE LOCATIONI provide or have provided rehabilitation technology equipment in the following areas: Home* 1 - Most of the time 2 - Some of the time 3 - Rarely/Not applicable School* 1 - Most of the time 2 - Some of the time 3 - Rarely/Not applicable Private Practice/Home Health Services* 1 - Most of the time 2 - Some of the time 3 - Rarely/Not applicable Inpatient Clinic* 1 - Most of the time 2 - Some of the time 3 - Rarely/Not applicable Outpatient Clinic* 1 - Most of the time 2 - Some of the time 3 - Rarely/Not applicable Adult Focused* 1 - Most of the time 2 - Some of the time 3 - Rarely/Not applicable Pediatric Focused* 1 - Most of the time 2 - Some of the time 3 - Rarely/Not applicable PRODUCT CATEGORIESI am involved in the provision of the following types of rehabilitation technology. Custom Manual Wheelchairs - Individually configured chairs that require adjustment such as axle position, seat to floor height, back angle, etc.* 1 - Most of the time 2 - Some of the time 3 - Rarely/Not applicable Complex Power Wheelchairs - Individually configured power base with power seating or custom seating & modification* 1 - Most of the time 2 - Some of the time 4 - Rarely/Not applicable Consumer Power Wheelchairs - Power base with Captain's base - Sit & Go* 1 - Most of the time 2 - Some of the time 3 - Rarely/Not applicable Cushions/Back Supports - Off the shelf seat cushions & back supports* 1 - Most of the time 2 - Some of the time 3 - Rarely/Not applicable Custom Seating Systems - Molded seating, shape capture and custom order linear seating* 1 - Most of the time 2 - Some of the time 3 - Rarely/Not applicable Specialty Drive Controls - Head array, sip & puff, switches & alternative drive controls* 1 - Most of the time 2 - Some of the time 3 - Rarely/Not applicable Environmental Control Units (ECU)* 1 - Most of the time 2 - Some of the time 3- Rarely/Not applicable Stander/Ambulatory Devices - Devices that must be fit to the individual, i.e. gait trainers, sit to stand standers that may require positioning components* 1 - Most of the time 2 - Some of the time 3- Rarely/Not applicable Scooters* 1 - Most of the time 2 - Some of the time 3 - Rarely/Not applicable Other (section B)If yes, provide explanation. Yes No If you answered "Yes" to "Other, please explain*DIAGNOSESMy area of practice includes. Spinal Cord Injury* 1 - Most of the time 2 - Some of the time 3 - Rarely/Not at all Cerebral Palsy* 1 - Most of the time 2 - Some of the time 3 - Rarely/Not at all Traumatic Brain Injury* 1 - Most of the time 2 - Some of the time 3 - Rarely/Not at all Muscular Dystrophy* 1 - Most of the time 2 - Some of the time 3 - Rarely/Not at all Multiple Sclerosis* 1 - Most of the time 2 - Some of the time 3 - Rarely/Not at all CVA* 1 - Most of the time 2 - Some of the time 3 - Rarely/Not at all ALS* 1- Most of the time 2 - Some of the time 3 - Rarely/Not at all Spina Bifida* 1 - Most of the time 2 - Some of the time 3- Rarely/Not at all Other (section C)If yes, provide explanation. Yes No If you answered "Other" please explain*Upload a copy of your business card and CEU Certificates*PDF is recommended. CEU Certificates earned within the past 18 months.Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.Affirmation of Good Moral CharacterWe require that you answer the following questions that address issues that may be harmful to the public or inappropriate to the profession. A “yes” answer will not necessarily result in a denial of registration or renewal. However, failure to fully disclose any relevant information will be considered grounds for denial of Registration or renewal. No applicant or Registrant will be denied registration or renewal solely on the grounds of conviction of a criminal offense. The nature of the offense, the date of the offense, the surrounding circumstances and the relevance of the offense will be considered. This includes any expunged records in any legal jurisdiction. If any sections have a “YES” answer, provide all details below. This will be kept confidential. 1. Have you ever been found guilty of, pled guilty or no contest to, entered into a plea agreement instead of prosecution, or found guilty without conviction (adjudication withheld) on a felony charge in any legal jurisdiction? Failure to disclose any relevant information will be considered grounds for denial* Yes No 2. Have you ever been found guilty of, pled guilty or no contest to, entered into a plea agreement instead of prosecution, or found guilty without conviction (adjudication withheld) on a misdemeanor involving theft, fraud, bribery, corruption, perjury, embezzlement, solicitation, dishonesty, physical harm or threat of physical harm to the person or property of another or substance abuse in any legal jurisdiction?* Yes No 3. Have you ever been subject to an adverse civil or administrative judgment for theft, fraud, corruption, embezzlement, solicitation, dishonesty, substance abuse, or any offense that calls into question the integrity or judgment of your actions?* Yes No 4. Are you currently or ever been subject to sanction, reprimand, suspension, or restriction by any governmental agency, professional body, association, licensing authority, board or certifying association of which you were or are a member or subject to its jurisdiction?* Yes No 5. Have you ever been discharged from employment for theft, fraud, corruption, embezzlement, solicitation, dishonesty, substance abuse, or any offense that calls into question the integrity or judgment of your actions?* Yes No Details*Applicant Signature*By signing below you affirm that your answers to the above questions are true and that you agree to abide by the NRRTS Code of Ethics; Standards of Practice and Blind Bidding Policy. I agree any dispute arising out of this application process shall be settled by arbitration. I agree to abide by the Code of Ethics, Standards of Practice and the Blind Bidding Policy of the National Registry of Rehabilitation Technology Suppliers. I certify to the best of my knowledge the above information is true and accurate.WORK EXPERIENCE VERIFICATION - MUST BE SIGNED BY A SUPERVISOR/MANAGERNRRTS will obtain your supervisor's signature on your behalf if your supervisor is not immediately available. Please complete the information.Continuous employment in years*A background check has been performed on this employee* Yes No Restriction of employment resulted from Background check* Yes No If YES, provide Detail with dates and restrictions noted below. This will be kept confidential.*Supervisor/Manager Name* First Last Supervisor/Manager Email* Supervisor/Manager's Phone*Supervisor/Manager's SignatureThis should be signed by a supervisor/manager. If your supervisor/manager is not available, NRRTS will obtain the signature. FORMER EMPLOYER (ONLY COMPLETE IF EMPLOYED BY CURRENT COMPANY LESS THAN ONE YEAR)Have you been with your current employer less than one year?If yes, complete the following questions. If no, skip to application fee section. Yes No The applicant was employed by (Name of Company)From Date MM slash DD slash YYYY To Date MM slash DD slash YYYY Former Supervisor/Manager Name First Last Former Supervisor/Manager Email UntitledEmailThis field is for validation purposes and should be left unchanged.
