QUOTE_SUBMISSION_QUESTIONAIRE.docx

QUOTE SUBMISSION QUESTIONAIRE

☐ Completed Schedule of Services (pages2-3) with proposed pricing for the One Year Base Period and Four (4) one-year option periods.

☐ Quoter confirms the attached Performance Work Statement (PWS) has been thoroughly reviewed before submitting a quotation, including Quote Submission Instructions in Section 4.5.1 and Evaluation of Quotes in Section 4.6

☐ The active registration in the System for Award Management (SAM) - www.SAM.gov .

☐ Quoter confirms the provision FAR 52.212-3, the annual representations and certifications, has been electronically completed at www.SAM.gov. The complete provision is attached to PWS.

☐ Contract Federal Tax ID Number is provided:__________________________

☐ Contractor DUNS number is provided:_________________________

Proof of General Insurance, in accordance with FAR 52.228-5;

☐ IS provided (1 page allowed each) OR ☐ CAN be provided before contract award.

Contractor’s Point of Contact (POC) Information is provided:

Name/Position: Email:

Phone: Fax:

☐ The following questions have been answered as provided below (maximum of 1 additional page allowed for each question, if necessary):

1. Is the Instructor certified, licensed, or accredited in the State of Wisconsin to provide instruction for the Certified Nurse Assistant Training Program?

2. Can the instructor provide a copy of the Certification annually to the Contracting Officer?

3. Is the instructor able to instruct in the classroom as well as on-the-job (OJT) setting. Please give example of past experiences. Does the instructor have experience and ability to work with disadvantage youth from various economic and social backgrounds without regard to race, creed, color, sex or national origin?

4. Can the instructor develop a curriculum, complete with lesson plans, class schedule, student tests, visual aids in accordance with course requirements as required by the State of Wisconsin?

☐ The following three (3) professional references of similar past work performance is provided:

1. Name: Organization:

Phone: Email:______________________________________

2. Name: Organization:

Phone: Email:______________________________________

3. Name: Organization:

Phone: Email:

☐ I certify that all of the information provided above is complete, true, and correct to the best of my knowledge.

Sign:______________________________________ Date:_______________________________________

AG-82A7-S-17-0079 Certified Nurse Assistant Instructor – Blackwell Job Corps Center Page 1 of 2