191728_OEMS-Application for Response~4.docx
DOCX document 59 KB Posted
- Attached to
- RFR 191728 EMT Chief Examiners
- Solicitation number
- BD-18-1031-BHCSQ-HCS06-27786
- Issued by
- Suffolk County, Massachusetts
About this file
This document is an Application Response Form for RFR 191728 issued by the Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health. The RFR is seeking Chief Examiners to perform Practical (Psychomotor) Testing for Emergency Medical Services (EMS) personnel. Respondents must indicate their preferred EMS region(s) to serve, and submit copies of licenses, certifications, resume/CV, and other required documents either through COMMBUYS or by mail. The response must be submitted within 7 days.
The document does not contain pricing terms, set asides, or information about incumbents, funding sources, or contract term and renewal options. It focuses on the application and submission requirements for interested individuals to serve as Chief Examiners for the practical testing component of the EMS certification process.
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Text version
The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health 250 Washington Street, Boston, MA 02108-4619
APPLICATION RESPONSE FORM
RFR TITLE : Chief Examiner Application for Practical (Psychomotor)Testing
RFR 191728
First Name: [ ] Last Name: [ ]
Title: [ ]
Address:
City: [ ] State: [ ] Zip: [ ]
Telephone: ( ) - FAX: ( ) -
E-Mail: [ ]
Commonwealth Vendor Customer Code (VCC)* (if available): [ ] Address Code: [ ] *for contract execution
PREFERRED LOCATION SERVED (select multiple if able) |_| EMS Region 1 |_| EMS Region 2 |_| EMS Region 3 |_| EMS Region 4 |_| EMS Region 5
APPLICATION PACKET
Application form and all attachments not requiring an INK signature must be submitted through COMMBUYS The following documents must be uploaded to COMMBUYS as part of the quote submission:
|_| The Application Response Form |_| Copies of credentials and CPR card. Attach copies of license(s) and certification(s). Include front and back of cards |_| Attach a résumé or CV detailing your experience in your priority health care or safety specialty.
|_| Prompt Payment Discount Form
The following documents must be signed in blue ink and mailed to Mark J. Miller at 99 Chauncy Street, 11th Floor, Boston, MA 02111 within 7 days of the quote submission on COMMBUYS.
|_| Completed CORI application with signatures and a copy of driver license |_| Commonwealth Terms and Conditions |_| Electronic Funds Transfer (EFT) |_| Verification of Taxation Reporting Information (W-9)
Signature: _______________________________________________Date: ___________________
5/25/18 image1.png
File details come from the government source that posted it. Updated .