17._Subcontractor-Consultant_List_(CCHCS-MC-391).pdf
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- Solicitation number
- 0000035871
- Issued by
- California
About this file
The document is a Subcontractor/Consultant List form from the California Correctional Health Care Services (CCHCS) for Bid Number SD24-00021, designed to capture detailed information about potential subcontractors or consultants for a state contract opportunity. The form provides a structured template for contractors to either indicate they will not use subcontractors or to list specific subcontractors/consultants, including their contact information, services to be performed, dollar amount of services, and business classification (small business, microbusiness, or Disabled Veteran Business Enterprise).
The form requires comprehensive documentation of any subcontractors, including their full name, street address, city, state, zip code, and phone number. Contractors are instructed to specify the services to be performed, the dollar amount of those services, and optionally mark whether the subcontractor falls under small business, microbusiness, or DVBE categories. The form also requests inclusion of the Department of General Services (DGS) Reference Number. This document appears to be part of a standardized procurement process that emphasizes transparency and potentially supports diversity in state contracting by highlighting different types of business enterprises.
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Text version
Contract Analyst: Kayla Jennings Bid Number: SD24-00021
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:
| DOLLAR AMOUNT |
| SERVICES TO BE PERFORMED |
| SMALL BUSINESS |
| OF SERVICES |
| I will NOT use any subcontractors or consultants in the performance of this Agreement: Off |
| NAME: |
| STREET ADDRESS: |
| CITY STATE ZIP: |
| PHONE NUMBER: |
| SERVICES TO BE PERFORMEDRow1: |
| DOLLAR AMOUNT OF SERVICESRow1: |
| SMALL BUSINESSRow1: |
| MICRO BUSINESSRow1: |
| DVBERow1: |
| NARow1: |
| DGS REFERENCE NUMBERRow1: |
| NAME_2: |
| STREET ADDRESS_2: |
| CITY STATE ZIP_2: |
| PHONE NUMBER_2: |
| SERVICES TO BE PERFORMEDRow2: |
| DOLLAR AMOUNT OF SERVICESRow2: |
| SMALL BUSINESSRow2: |
| MICRO BUSINESSRow2: |
| DVBERow2: |
| NARow2: |
| DGS REFERENCE NUMBERRow2: |
| NAME_3: |
| STREET ADDRESS_3: |
| CITY STATE ZIP_3: |
| PHONE NUMBER_3: |
| SERVICES TO BE PERFORMEDRow3: |
| DOLLAR AMOUNT OF SERVICESRow3: |
| SMALL BUSINESSRow3: |
| MICRO BUSINESSRow3: |
| DVBERow3: |
| NARow3: |
| DGS REFERENCE NUMBERRow3: |
| NAME_4: |
| STREET ADDRESS_4: |
| CITY STATE ZIP_4: |
| PHONE NUMBER_4: |
| SERVICES TO BE PERFORMEDRow4: |
| DOLLAR AMOUNT OF SERVICESRow4: |
| SMALL BUSINESSRow4: |
| MICRO BUSINESSRow4: |
| DVBERow4: |
| NARow4: |
| DGS REFERENCE NUMBERRow4: |
| NAME_5: |
| STREET ADDRESS_5: |
| CITY STATE ZIP_5: |
| PHONE NUMBER_5: |
| SERVICES TO BE PERFORMEDRow5: |
| DOLLAR AMOUNT OF SERVICESRow5: |
| SMALL BUSINESSRow5: |
| MICRO BUSINESSRow5: |
| DVBERow5: |
| NARow5: |
| DGS REFERENCE NUMBERRow5: |
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