1-Appendix 1 - Applicant Profile.docx

Appendix 1 – Applicant Profile Notice: With few exceptions, individuals are entitled on request to be informed about the information that governmental bodies of the State of Texas collect about such individuals. Under 552.021 and 552.023, Texas Government Code, individuals are entitled to receive and review such information. Under 559.004, Texas Government Code, individuals are entitled to have governmental bodies of the State of Texas correct information about such individuals that is incorrect.

Applicant may detail responses in the chart below. In cases where a question does not apply, or the Applicant is unable to respond, Applicant shall indicate “N/A” (Not Applicable) or “N/R” (No Response), as appropriate. Applicant will explain the reason when responding with “N/A” or “N/R.”

1 – APPLICANT PROFILE

1.1 Legal Name of Applicant Organization

[INSERT RESPONSE]

1.2 Address of Principal Place of Business

1.3 Address of Office(s) that would be providing Service under this Agreement

1.4 Administrative Contact Name, Phone Number, and E-Mail Address

1.5 Project Director/Principal Investigator Name, Phone Number, and E-Mail Address

1.6 Financial Contact Name, Phone Number, and E-Mail Address

1.7 Authorized Official Name, Phone Number, and E-Mail Address

1.8 Number of Years in Business

1.9 State of Incorporation

1.10 Number of Employees

1.11 Annual Revenue

1.12 Name of Parent Corporation (if any)

(Note: If Applicant is a subsidiary, Be Well Texas prefers to enter into a contract/agreement with the Parent Corporation or to receive expressed assurances of performance from the Parent Corporation)

1.13 State whether Applicant will provide a copy of its financial statements for the past two (2) years, if requested by BWTX.

1.14 Is Applicant currently for sale or involved in any transaction to expand or to become acquired by another entity? If yes, Applicant will explain the expected impact both in organizational and directional terms.

1.15 Applicant will provide any details of all past or pending litigation or claims filed against Applicant that would affect its performance under the agreement with Be Well Texas (if any).

1.16 Is Applicant currently in default on any loan agreement or financing agreement with any bank, financial institution, or other entity? If yes, Applicant will specify the pertinent date(s), details, circumstances, and describe the current prospects for resolution.

1.17 Applicant will provide a reference list of no less than three (3) organizations with which Applicant currently works with and/or to which Applicant has previously worked with (within the past five (5) years). Applicant will include in its reference list the organization name, contact person, telephone, number, project description, length of business relationship, and background of services provided by the Applicant.

REFERENCE ONE

Organization Name

Contact Person Name & E-mail

Reference Project Description

Length of Relationship with this Organization

Background of Services Provided by Applicant

REFERENCE TWO

Organization Name

Contact Person Name & E-mail

Reference Project Description

Length of Relationship with this Organization

Background of Services Provided by Applicant

REFERENCE THREE

Organization Name

Contact Person Name & E-mail

Reference Project Description

Length of Relationship with this Organization

Background of Services Provided by Applicant