40DHHS-S3649-Vendor-Information-Response.pdf

This is a Vendor Information Response form issued by the Nevada Department of Health and Human Services (DHHS) for state and local contract opportunities. The form serves as a standardized template that vendors must complete and submit with their proposals. Vendors are required to provide comprehensive company contact information, including company name, street address, telephone numbers, email addresses, and designated contact persons for questions and contract negotiations. If a proposal includes subcontractors, the form must be completed for each subcontractor as well. The document outlines mandatory disclosure requirements and certification obligations that vendors must satisfy as part of the proposal submission process.

The form requires vendors to disclose critical organizational and operational information, including company profiles, current licensing status with the Nevada Secretary of State's Office, and any prior experience with State of Nevada agencies. Vendors must disclose employment of current or former state employees within the past two years who will perform work under the contract. Additionally, vendors must reveal any significant prior or ongoing contract failures, breaches, civil or criminal litigation, or pending claims occurring within the past six years that may affect their ability to perform contractual obligations. The form also includes sections for payment authorization for procurement card use and requires identification and signature of the individual authorized to bind the vendor organization, along with mandatory certifications regarding lobbying and indemnification.