1. Responder Contact Information - SFGOV-0000011976.pdf
PDF 343 KB Posted
- Solicitation number
- SFGOV-0000011976
- Issued by
- San Francisco County, San Francisco City, California
About this file
This is a Responder Contact Information cover sheet for an RFQ issued by the San Francisco Department of Public Health (SFGOV-0000011976) for the establishment of a prequalified list of vendors to provide as-needed technical assistance and consulting services. Respondents may apply for one or more of four service categories: Public Health Grant and Research Development; Public Health Organizational Development, Technical Assistance and Training; Public Health Program Evaluation and Community Needs Assessment; and Public Health Program Implementation and Project Management. The document requires respondents to provide their organizational information, authorized representative contact details, and confirm their good standing status in California with all necessary licenses and permits.
Respondents must certify their willingness to comply with all terms and conditions contained in the attached Agreement Templates and Business Associate Agreement (BAA) in Attachment A-3 without modification, with the understanding that the City reserves the right to terminate negotiations if a satisfactory contract cannot be negotiated within a reasonable timeframe. The document does not specify pricing terms, funding amounts, response deadlines, or contract duration on this cover sheet, as this appears to be a preliminary intake form for vendor qualification rather than a complete solicitation document.
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Text version
SOURCING EVENT ID: SFGOV-0000011976
RFQ FOR THE ESTABLISHMENT OF A PREQUALIFIED LIST
FOR AS-NEEDED TECHNICAL ASSISTANCE AND CONSULTING SERVICES
FOR THE DEPARTMENT OF PUBLIC HEALTH
COVER SHEET
Responder Contact Information and Representations
1. Responder is applying for the following Service Categories (check all that apply):
2. Responder’s Description.
Responder’s name and organizational structure (e.g., non-profit, for-profit, corporation, partnership, limited liability company), the State in which Responder is registered and date of such registration.
3. Authorized Representative.
The name, address, telephone number, and facsimile number of the employee listed below is authorized to act on behalf of Responder for purposes of this solicitation:
Name:
Address:
Phone: Fax: Email:
4. Certification re: Good Standing, Licenses, etc.
Responder is in good standing in the State of California and has all necessary licenses, permits, approvals and authorizations necessary to perform the solicitation scope of work. (Please check the item below if you agree with this statement.)
I hereby represent and certify that the above statement is true and correct.
5. Certification re: City Contracting Requirements.
Responder will comply with all City contracting requirements. (Please check the items below if you agree with this statement.)
Responder agrees to and will comply with all terms and conditions of the attached Agreement Template(s), contained in Attachment A-3, including all Appendices, without modification. If a satisfactory contract(s) cannot be negotiated in a reasonable time, the City, in its sole discretion, may terminate negotiations.
Responder agrees to and will comply with all terms and conditions of the attached Business Associate Agreement (“BAA”) and attestations, contained in Attachment A-3, without modification. If a satisfactory contract(s) cannot be negotiated in a reasonable time, the City, in its sole discretion, may terminate negotiations.
PRINT NAME SIGNATURE/DATE
Category 1: Public Health Grant and Research Development
Category 2: Public Health Organizational Development, Technical Assistance and Training
Category 3: Public Health Program Evaluation and Community Needs Assessment
Category 4: Public Health Program Implementation and Project Management
| 1. Proposer is applying for the following Service Categories (check all that apply): |
| 2. Proposer’s Description. |
| 3. Authorized Representative. |
| Name: |
| 4. Certification re: Good Standing, Licenses, etc. |
| 5. Certification re: City Contracting Requirements. |
| Name: |
| Address: |
| Phone: |
| Fax: |
| Email: |
| I hereby represent and certify that the above statement is true and correct: |
| Templates contained in Attachment A3 including all Appendices without modification If a: |
| Proposer agrees to and will comply with all terms and conditions of the attached Business: |
| Proposer’s Description: |
| Check Box5: Off |
| Check Box6: Off |
| Check Box9: Off |
| Check Box10: Off |
File details come from the government source that posted it. Updated .