41NHA-S4031-Vendor-Information-Response.pdf

This is a Vendor Information Response form established by the Nevada Health Authority (NVHA) for the Rural Value Acceleration Network (RVAN) Vendor procurement. The form, revised in April 2021, requires vendors and any subcontractors to complete and submit comprehensive company information as part of their proposal response. The document serves as a standardized template for collecting essential vendor details necessary for contract development and execution.

The form mandates disclosure of company contact information, primary contact person details, overall company profile, vendor licensing status, and prior experience with State of Nevada agencies. Vendors must confirm compliance with Nevada Revised Statutes (NRS) 80.010 regarding foreign corporation registration with the Secretary of State's Office and NRS 76 regarding appropriate state business licensing. Additionally, vendors are required to disclose any current or former State of Nevada employees involved in contract performance, any prior or ongoing contractual issues including breaches or litigation within the past six years that may affect performance capability, and payment authorization for procurement card use. The form concludes with authorization for an individual authorized to bind the organization, requiring signature and comprehensive contact information for both the company and the authorized representative.