6-RFP 06 Request for Client Information Form.pdf
PDF 175 KB Posted
- Attached to
- Health Commons Services
- Solicitation number
- RFP27-33
- Issued by
- Los Alamos County, New Mexico
About this file
This is a Request for Client Information Form issued by the Incorporated County of Los Alamos Procurement Division in New Mexico for a Health Commons Services contract opportunity. The form is designed to collect information about offerors' previous or current clients to verify their experience providing similar services. Offerors are required to provide a minimum of three client references from work performed within the last 3 to 5 years. Each client reference must include the company name, address, contact name and position, email address, telephone number, period of service, a description of services provided, and the outcome of the engagement. The County reserves the right to contact any or all listed clients to verify information and request additional details.
The form allows offerors to submit up to five client references and indicates that if previous or current client information is confidential, offerors may state so; however, if client information is a scored evaluation criterion, omission or inability to provide complete information will result in lower evaluation scores. The form itself does not contain pricing terms, set-asides, funding information, or contract duration details. Those specifications would be contained in the complete Request for Proposals (RFP) document for the Health Commons Services contract, which includes family planning, STI screening and treatment, primary care services, and behavioral health services.
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Text version
REQUEST FOR CLIENT
INFORMATION
Incorporated County of Los Alamos Procurement Division
101 Camino Entrada, Building 3 Los Alamos, NM 87544
Version:20250318
Please follow the instructions below to provide information about previous or current clients as requested in this form.
1. The County reserves the right to contact some or all of the clients listed to verify any information provided and to request that they provide additional information.
2. If previous client information is confidential, you may state so; however, if previous or current client information is a scored evaluation criteria, evaluation scores will reflect Offeror’s inability to include some or all of the requested information in the bid or proposal.
3. Provide a minimum of 3 previous or current clients for similar services performed in the last 3-5 years.
4. Information provided should include company name, address, contact name, position, e-mail address, telephone number, the period during which services were provided, a description of the services provided, and outcome of the engagement.
GENERAL INFORMATION
Offeror Company Name:
Solicitation No.:
Solicitation Title:
Name and Title of the Person Completing this Form
PREVIOUS OR CURRENT CLIENT INFORMATION
CLIENT 1
Company Name
Address
Contact Name and Position
E-mail Address
Telephone Number
Period During Which Services Were Provided
MM/DD/YY – MM/DD/YY
Description of Services Provided and Outcome of the Engagement
CLIENT 2
Company Name
Address
Contact Name and Position
E-mail Address
Telephone Number
Period During Which Services Were Provided
MM/DD/YY – MM/DD/YY
CLIENT 3
Address
Contact Name and Position
E-mail Address
Telephone Number
CLIENT 4
Address
Contact Name and Position
E-mail Address
Telephone Number
CLIENT 5
Company Name
Address
Contact Name and Position
E-mail Address
Telephone Number
Period During Which Services Were Provided
MM/DD/YY – MM/DD/YY
| Company Name: |
| Address: |
| Contact Name and Position: |
| Email Address: |
| Telephone Number: |
| Period During Which Services Were Provided MMDDYY MMDDYY: |
| Description of Services Provided and Outcome of the Engagement: |
| Company Name_2: |
| Address_2: |
| Contact Name and Position_2: |
| Email Address_2: |
| Telephone Number_2: |
| Period During Which Services Were Provided MMDDYY MMDDYY_2: |
| Description of Services Provided and Outcome of the Engagement_2: |
| Company Name_3: |
| Address_3: |
| Contact Name and Position_3: |
| Email Address_3: |
| Telephone Number_3: |
| Period During Which Services Were Provided MMDDYY MMDDYY_3: |
| Description of Services Provided and Outcome of the Engagement_3: |
| Company Name_4: |
| Address_4: |
| Contact Name and Position_4: |
| Email Address_4: |
| Telephone Number_4: |
| Period During Which Services Were Provided MMDDYY MMDDYY_4: |
| Description of Services Provided and Outcome of the Engagement_4: |
| Company Name_5: |
| Address_5: |
| Contact Name and Position_5: |
| Email Address_5: |
| Telephone Number_5: |
| Period During Which Services Were Provided MMDDYY MMDDYY_5: |
| Description of Services Provided and Outcome of the Engagement_5: |
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