2a.Customer Cert Form for Category 1 - SFGOV-11976.pdf

This is a Customer Certification Form for the City and County of San Francisco, Department of Public Health, related to Sourcing Event ID SFGOV-0000011976, an RFQ for the establishment of a prequalified list for as-needed technical assistance and consulting services. The form is specifically designated for Category 1: Public Health Grant and Research Development and is to be completed and signed by the responder's customer to certify that the responder has successfully applied for and been awarded public health grant funds for a public health organization. The form requires the customer to provide their organization name, location, and the name and title of the customer representative completing the certification, along with that representative's signature, date, phone number, and email address.

The form includes provisions for multiple customer references and requires valid contact information to be submitted by respondents. The City reserves the right to contact the listed customer reference up to three times to verify the services indicated. Any proposer who submits invalid customer contact information or whose customer contact is unreachable may be deemed non-responsive. The form does not specify pricing terms, award dates, contract term, or renewal options, as it functions solely as a verification mechanism to validate the responder's experience and qualifications within the public health grant and research development category.