3-Non-Collusion Statement -Attcahment 2.pdf
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- Solicitation number
- HSS-26-014
- Issued by
- Delaware
About this file
This is a Non-Collusion Statement form attachment for the Delaware Department of Health and Social Services, Division of Public Health, soliciting proposals to operate School-Based Health Centers for Adolescents across nineteen school districts. The contract, identified as HSS-26-014, requires vendors to submit proposals addressing thirty-two school-based health centers across the state's targeted school districts. The solicitation deadline is January 28, 2026, at 1:00 PM EST/EDT. The primary mission of the program is to provide prevention-oriented, multidisciplinary health services to adolescents within public school environments, complementing existing school-based supports and coordinating with students' established medical homes or primary care providers.
The form requires the authorized representative's signature and certifies that the vendor has not engaged in collusion or restraint of free competitive bidding and is not a sub-contractor to another primary vendor submitter. Vendors must disclose company classifications including Minority Business Enterprise (MBE), Woman Business Enterprise (WBE), Disadvantaged Business Enterprise (DBE), Veteran Owned Business Enterprise (VOBE), and Service-Disabled Veteran Owned Business Enterprise (SDVOBE) status. The form includes an affirmation section requiring disclosure of any suspension or debarment actions against the firm, its affiliates, predecessor entities, or company principals within the past five years. Vendors must provide company contact information, federal E.I. number, and designate an address for purchase order delivery.
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Text version
Delaware Health and Social Services Division of Public Health
Attachment 2
CONTRACT NO.: HSS-26-014
CONTRACT TITLE: School-Based Health Centers for Adolescents in Nineteen School Districts DEADLINE TO RESPOND: January 28, 2026, at 1:00 PM EST/EDT
NON-COLLUSION STATEMENT (COMPLETE THIS FORM IN ITS ENTIRELY)
This is to certify that the undersigned Vendor has neither directly nor indirectly, entered into any agreement, participated in any collusion or otherwise taken any action in restraint of free competitive bidding in connection with this proposal, and further certifies that it is not a sub-contractor to another Vendor who also submitted a proposal as a primary Vendor in response to this solicitation submitted this date to the State of Delaware, Division of Public Health.
It is agreed by the undersigned Vendor that the signed delivery of this bid represents, subject to any express exceptions set forth at Attachment 3, the Vendor’s acceptance of the terms and conditions of this solicitation including all specifications and special provisions.
NOTE: Signature of the authorized representative MUST be of an individual who legally may enter his/her organization into a formal contract with the State of Delaware, Division of Public Health.
COMPANYNAME (Check one)
NAME OF AUTHORIZED REPRESENTATIVE
(Please type or print)
SIGNATURE TITLE
COMPANY ADDRESS
PHONE NUMBER FAX NUMBER
EMAIL ADDRESS ______________________________
STATE OF DELAWARE
FEDERAL E.I. NUMBER LICENSE NUMBER_____________________________
COMPANY
CLASSIFICATIONS:
CERT. NO.:
Certification type(s) Circle all that apply
Minority Business Enterprise (MBE) Yes No Woman Business Enterprise (WBE) Yes No Disadvantaged Business Enterprise (DBE) Yes No Veteran Owned Business Enterprise (VOBE) Yes No Service-Disabled Veteran Owned Business Enterprise (SDVOBE) Yes No
[The above table is for informational and statistical use only.]
PURCHASE ORDERS SHOULD BE SENT TO:
(COMPANY NAME)
ADDRESS
CONTACT
PHONE NUMBER FAX NUMBER
EMAIL ADDRESS
AFFIRMATION: Within the past five years, has your firm, any affiliate, any predecessor company or entity, owner, Director, officer, partner or proprietor been the subject of a Federal, State, Local government suspension or debarment?
YES NO if yes, please explain
Corporation Partnership Individual
File details come from the government source that posted it. Updated .