193424 MDPH Attorney Services and Legal Support Sercvices Application for Response~1.docx

The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health Purchase of Service Office 250 Washington Street, Boston, MA 02108-4619

APPLICATION RESPONSE FORM

RFR TITLE MDPH Attorney Services and Legal Support Services

RFR# 193424

Bidder Name: [ ]

Address:

City: [ ] State: [ ] Zip: [ ]

Contact Person: First Name: [ ] Last Name: [ ]

Title: [ ]

Telephone: ( ) -

FAX: ( ) -

E-Mail: [ ]

Commonwealth Vendor Customer Code (VCC)* (if available): [ ] Address Code: [ ] *for contract execution

Categories

Which Categories are you applying for?

|_| Category 1. Lead Poisoning

|_| Category 2. Guardianship

|_| Category 3. Other: [ ]

|_| Category 4: Non Attorney Legal Support Services:

Legal SPECIALTY Both individuals and organizations should describe professional experience in the category(s) checked above including experience in cases related to the categories worked in the last three years.

Enter text here;text limit 18,000 Characters

PROFESSIONAL EXPERIENCE

Organizations describe the size, structure, areas of practice and office locations

Enter text here; text limit 18,000 charaters

|_| Individuals provide Résumé(s) or CV(s) detailing the experience

|_| Copies of relevant licenses and certifications attached (if applicable)

RATES

List your maximum rates for your specialty legal services.

Maximum Hourly Rate(s)*: [$ ] or attach a detailed itemized fee schedule.

*Set for the initial duration of the contract.

PREFERRED REGION SERVED

Please indicate the geographic region(s) of the state that you prefer to serve.

Enter text here; text limit 1250

Applicant affirms by signing below, that all individuals that work on a project for DPH will be appropriately licensed and/or Board certified. A copy of license(s) and/or certificate(s) may be required at the time of engagement.

Authorized Signatory:

First Name: [ ] Last Name: [ ]

Title: [ ]

By clicking the check box, the submitter attests that s/he is an agent of the Bidder with authority to sign on the Bidder’s behalf.

APPLICATION PACKET

|_| The Application Response Form

|_| Attach copies of credentials. Attorneys must be members of the Massachusetts Bar. Attach copies of BBO Registration.

|_| Attach a résumé or CV detailing your experience in your specialty area.

|_| Business Reference Form

|_| The forms listed on the COMMBUYS attachments screen for this RFR must be completed and submitted with your response in accordance with the instructions on the screen.

APPLICATION INSTRUCTIONS

1. Upload in COMMBUYS the Application Response Form with the required attachments

2. Submit your electronic quote in COMMBUYS. (Vendors must be registered in COMMBUYS to submit quotes) image1.png