40DHHS-S3579-Vendor-Information-Response.pdf

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Attached to
Medical Director for NYTC
Solicitation number
40DHHS-S3579
Issued by
Elko County, Nevada

About this file

This is a Vendor Information Response form developed by the Nevada Department of Human Services for submission with proposals related to RFP 40DHHS-S3579 for medical director services at the Nevada Youth Training Center (NYTC). The form requires vendors and any subcontractors to provide comprehensive company contact information, including company name, address, telephone, email, and designated contact person for contract negotiations. Vendors must also disclose their Nevada experience with state agencies, current or former employment of state workers, and any prior or ongoing contractual issues, failures, or litigation involving the State of Nevada or its political subdivisions occurring within the past six years. The proposal deadline is February 25, 2026, at 2:00 pm Pacific Time, with questions due by February 4, 2026, and client references required by February 23, 2026. The resulting contract will be for a four-year term subject to automatic renewal unless terminated by legislative action due to insufficient funding.

The form requires vendors to certify their authorization to bind the organization and complete payment authorization for procurement card use. Prior to contract execution, vendors must register as foreign corporations with the Nevada Secretary of State's Office if organized in another state and obtain an appropriate Nevada business license pursuant to NRS 76. The solicitation applies a five percent preference to Nevada-based businesses as defined by NRS 333.3351-333.3356 and imposes inverse preferences on vendors from states that restrict Nevada vendors. All vendors must register with nevadaepro.com, maintain active entity registration with sam.gov, and comply with mandatory requirements including Nevada's Israel boycott prohibition, data encryption and stateside maintenance, indemnification provisions, and insurance coverage requirements detailed in the standard form independent contractor services agreement and insurance schedule.

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VENDOR INFORMATION RESPONSE

Revised: April 2021 Page 1 of 1

Vendors shall complete and return this form in their proposal.

If the proposal includes subcontractors, form must be completed for each subcontractor as well.

1. VENDOR CONTACT INFORMATION

COMPANY NAME AND CONTACT INFORMATION:

The information provided in the table below shall be used for development of the contract, if awarded.

Requested Information Response

Company Name:

Company Street Address:

City, State, Zip Code:

Telephone Number, including area code:

Toll Free Number, including area code:

Email Address:

CONTACT PERSON FOR QUESTIONS/CONTRACT NEGOTIATIONS

Requested Information Response

Name:

Title:

Address:

City, State, Zip Code:

Email Address:

Telephone Number, including area code:

Toll Free Number, including area code:

Confidentiality and Certification of Indemnification
Certification Regarding Lobbying
Vendor Information Response
1. VENDOR CONTACT INFORMATION
1.1 COMPANY NAME AND CONTACT INFORMATION:
1.2 CONTACT PERSON FOR QUESTIONS/CONTRACT NEGOTIATIONS
2. VENDOR INFORMATION
2.1 Vendors shall provide an overall company profile in the following table:
2.2 VENDOR LICENSING
2.2.1 Please be advised: Pursuant to NRS 80.010, a corporation organized pursuant to the laws of another state shall register with the State of Nevada, Secretary of State’s Office as a foreign corporation before a contract can be executed between the ...
2.2.2 The selected vendor, prior to doing business in the State of Nevada, shall be appropriately licensed by the State of Nevada, Secretary of State’s Office pursuant to NRS 76. Information regarding the Nevada Business License can be located at htt...
2.3 STATE OF NEVADA EXPERIENCE
2.3.1 If ‘Yes’, complete the following table for each State agency for whom the work was performed.
2.3.2 Table can be duplicated for each contract being identified.
2.4 CURRENT OR FORMER EMPLOYEE
2.4.1 If you employ (a) any person who is a current employee of an agency of the State of Nevada, or (b) any person who has been an employee of an agency of the State of Nevada within the past two (2) years, and if such person shall be performing or p...
2.5 PRIOR OR ONGOING CONTRACTUAL ISSUES
2.5.1 Disclosure of any significant prior or ongoing contract failures, contract breaches, civil or criminal litigation in which the vendor has been alleged to be liable or held liable in a matter involving a contract with the State of Nevada or any o...
2.5.2 Any pending claim or litigation occurring within the past six (6) years which may adversely affect the vendor’s ability to perform or fulfill its obligations if a contract is awarded as a result of this RFP shall also be disclosed.
2.5.3 If ‘Yes’, please provide the information in the table below.
2.5.4 Table can be duplicated for each issue being identified.
3. PAYMENT AUTHORIZATION FOR USE OF PROCUREMENT CARD
4. NAME OF INDIVIDUAL AUTHORIZED TO BIND THE ORGANIZATION
4.1 SIGNATURE OF INDIVIDUAL AUTHORIZED TO BIND THE VENDOR
Company Name:
Company Email Address:
Contact Person Name:
Contact Person Title:
Contact Person Address:
Contact Person City, State, Zip Code:
Contact Person Email:
Contact Person Telephone:
Contact Person Toll Free (if applicable):
Company Address:
Company City State Zip Code:
Company Telephone:
Company Toll Free:

File details come from the government source that posted it. Updated .