10._CCHCS-MC-391-_Subcontractor-Consultant_List.pdf

Contract Analyst: Kayla Jennings

Proposal Number: SD23-00097

CCHCS-MC-391 – Subcontractor/Consultant List Rev. 03/08/2018

SUBCONTRACTOR/CONSULTANT LIST

I will NOT use any subcontractors or consultants in the performance of this Agreement.

The following information MUST be provided for ALL subcontractors or consultants used by the contractor to perform any labor or render any services under this Agreement. In addition, if known, please indicate whether the subcontractor or consultant is a small business, microbusiness, and/or Disabled Veteran Business Enterprise (DVBE) by placing an “X” in the appropriate column and include their Department of General Services (DGS) Reference Number. If a subcontractor(s) or consultant(s) will be used, but no selection has been made, identify the service and estimate the dollar amount of services. If additional space is needed, supplementary sheets in the format below may be attached to this list.

SUBCONTRACTOR OR CONSULTANT

NAME, ADDRESS, AND PHONE NUMBER

SERVICES TO BE PERFORMED

DOLLAR AMOUNT

OF SERVICES

CHECK IF A

DGS REFERENCE

NUMBER SMALL

BUSINESS

MICRO-

BUSINESS

DVBE N/A

NAME:

STREET ADDRESS:

CITY, STATE, ZIP:

PHONE NUMBER:

NAME:

STREET ADDRESS:

CITY, STATE, ZIP:

PHONE NUMBER:

NAME:

STREET ADDRESS:

CITY, STATE, ZIP:

PHONE NUMBER:

NAME:

STREET ADDRESS:

CITY, STATE, ZIP:

PHONE NUMBER:

NAME:

STREET ADDRESS:

CITY, STATE, ZIP:

PHONE NUMBER: