Company name *

Your First Name *

Your Last Name *

Your role or title *

Phone number *

Business email (recommended — we send review updates and document requests by email)

Primary service category *

Counties served *

Ellis County, TX

Dallas County, TX

Tarrant County, TX

Other / Outside area

Cities or ZIP codes served (optional)

Licensed and insured for this service *

Yes

No

License not required for this service

Website (optional)

Brief description of service (optional)

I’m interested in the Vendor Visibility Package. I understand it provides advertising exposure only, not guaranteed inquiries or referrals, and requires approval as a Dignity vendor and a signed sponsor agreement.

Yes

Medical vendors (Home Care, Pharmacy, Medical Equipment, Medical Provider, Mobile Medical Services) are not eligible, because of the federal Anti-Kickback Statute, 42 U.S.C. § 1320a-7b(b), and Texas Occupations Code Chapter 102.

Authorization to contact *

I authorize Dignity Living Solutions to contact me about becoming an approved vendor

I agree to receive text messages from Dignity Living Solutions about this inquiry at the phone number above. Message frequency varies. Message and data rates may apply. Reply STOP to opt out or HELP for help. Consent is not required to submit this form.

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