36C26318Q0535-001.docx

Sources Sought Notice Response Form for Non-Emergency Ambulance Transport Services – VA Nebraska-Western Iowa Health Care System

Please fully complete each section of the form below.

Company Name: _____________________________________________________________ Company Address: ___________________________________________________________ DUNS Number: _____________________________________________________________ Point of Contact: ____________________________________________________________ Phone Number: _____________________________________________________________ Email Address: _____________________________________________________________

Socio-Economic Classification in Accordance with NAICS Code 621910 – Ambulance Service (check all that apply) ☐ Small Business ☐ Service Disabled Veteran Owned Small Business (SDVOSB) ☐ Verified SDVOSB by www.vip.vetbiz.gov ☐ Veteran Owned Small Business (VOSB) ☐ Verified VOSB by www.vip.vetbiz.gov ☐ Small Disadvantage Business ☐ Women-owned Small Business ☐ Economically Disadvantaged Small Business ☐ HUBZone ☐ 8(a) Certified ☐ Other: _________________________________________________

Businesses desiring to do business with the Federal Government are required to be active and registered at System for Award Management (SAM) at https://www.sam.gov; is your business registered at this site? Yes ___No ____ If yes, please provide copy of SAM registration.

Detailed Information:

1. Please summarize your company’s ability to provide non-emergency ambulance transport services as contained in Sources Sought Notice posted to https://www.fbo.gov:

2. What percentage of the contracted services can your company complete as the prime contractor? ______________%

3. What percentage of the contracted services would your company subcontract? ______________%

4. If solicitation is pursued after market research conducted, the Government will required that company have Emergency Medical Services Advanced Life Support (ALS) licensure through the State of Nebraska Health and Human Services (http://dhhs.ne.gov/publichealth/Licensure/Documents/EMSServiceRequirements.pdf)

a) Does your company have a current license from Nebraska or other state? If so, please provide a copy of such license in response to this notice

b) If does not, does company anticipate being able to obtain such licensure if solicitation is contemplated by the Government?

Please explain: