25._Contractor_Contact_Info_(CCHCS-MC-332).pdf
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- Solicitation number
- 0000035871
- Issued by
- California
About this file
This document is a Contractor Contact Information form from the California Correctional Health Care Services (CCHCS) for Bid Number SD24-00021, specifically focused on Prosthetic and Orthotic Services and Devices. The form is designed to collect and maintain up-to-date contact information for contractors providing services to the California Department of Corrections and Rehabilitation, with the primary purpose of enabling institutions to reach out to service providers when needed.
The form requires contractors to provide their company name (matching the legal business name on STD 204), telephone and fax numbers, and details of an authorized representative. Contractors are instructed to submit a new form to the CCHCS Direct Care Contracts Section Help Desk if there are any changes to their contact information, with a separate form required for each service type if a company is awarded multiple contracts. The document emphasizes the contractor's responsibility to maintain current contact information, which will be included on the award matrix posted on the California Department of Corrections and Rehabilitation's internet website.
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Text version
Bid Number: SD24-00021
CCHCS-MC-332 – Contractor Contact Information Rev. 11/01/2017
CONTRACTOR CONTACT INFORMATION
The information provided below is included on the award matrix posted on the California Department of Corrections and Rehabilitation Internet website. This information is used by institutions to contact your company to request services. It is the contractor’s responsibility to submit a new form to California Correctional Health Care Services (CCHCS) if there are any changes to the telephone number and/or fax number provided below. If your company was awarded a contract for more than one service, then a separate form for each service type is required. Submit the completed form(s) to the CCHCS Direct Care Contracts Section Help Desk at: cchcshealthcarecontractshelpdesk@cdcr.ca.gov.
Type of Service: Prosthetic and Orthotic Services and Devices
Company Name: (Must be identical to the payee’s legal business name listed on the STD 204)
Telephone Number: Fax Number:
Name of Authorized Representative: Title:
Signature of Authorized Representative: Date:
| Company Name Must be identical to the payees legal business name listed on the STD 204: |
| Telephone Number Fax Number: |
| Name of Authorized Representative Title: |
| Date: |
| Text1: |
| Text2: |
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