256835 CHC Application.docx
DOCX document 29 KB Posted
- Attached to
- 256835 Community Health Center
- Solicitation number
- BD-25-1031-ADMIN-ADM07-111036
- Issued by
- Massachusetts
About this file
This is an application form template for RFR #256835, issued by the Department of Public Health (DPH), for Community Health Centers seeking to be added to a pre-qualified vendor list. The application requires basic organizational information including name, address, vendor code, EIN, and contact details for the applying entity.
The form specifically targets two types of eligible entities: Community Health Centers as defined by 42 U.S.C. section 254(b) and Hospital Licensed Health Centers. Applicants must acknowledge that prequalification does not guarantee specific engagements or funding from DPH. The application serves as a preliminary screening mechanism for potential future funding opportunities, rather than a direct contract award process.
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Other files
| File | Type | Posted |
|---|---|---|
| 256835 RFR CHC~1.docx | DOCX document | |
| INFO2~21.zip | ZIP file | |
| READ2~16.zip | ZIP file | |
| 256835 Evaluation Criteria.docx | DOCX document |
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Text version
RFR #256835 – Community Health Centers
Application Response
| ORGANIZATION NAME: |
| ADDRESS: |
| VENDOR CODE: |
| EIN: |
| CONTACT PERSON: |
| TITLE: |
| TELEPHONE: |
| FAX: |
| EMAIL: |
| CONTACT PERSON ADDRESS (if different): |
A COMPLETE RFR RESPONSE MUST INCLUDE:
· An application response form
Application Form
1. Applicant Name
2. Please specify your eligibility type.
☐ Community Health Center, as defined by 42 U.S.C. section 254(b) ☐ Hospital Licensed Health Center
3. By selecting yes, the applicant is expressing its interest in being added to a pre-qualified list of approved vendors, namely community health centers, to be eligible for potential future funding from the Department of Public Health (DPH). The applicant understands and acknowledges that prequalification does not entitle the applicant to a specific engagement or funding.
☐ Yes ☐ No
By submitting this application, you have attested that the information included in this application is accurate.
File details come from the government source that posted it. Updated .