Appendix A - Application Coversheet.pdf
PDF 234 KB Posted
- Attached to
- HEZ Community Health Workers State and local contract opportunity
- Solicitation number
- 25-RFA-13139
- Issued by
- Philadelphia County, Philadelphia City, Pennsylvania
About this file
This document is an Application Cover Sheet for a Request for Application (RFA) issued by the Commonwealth of Pennsylvania's Department of Human Services, specifically RFA number 25-RFA-13139. The cover sheet is a standardized form designed for potential applicants to provide their organizational details and confirm their submission of two separate application components: a Technical Submittal and a Cost Reimbursement Cost Submittal.
The form requires applicants to provide comprehensive organizational information, including the applicant's name, mailing address, website, contact person details, organization type (with options for For Profit, Not-For-Profit, Local Government, or Other), Federal ID Number, SAP/SRM Vendor Number, and Unique Entity Identifier. A critical requirement is the signature of an authorized official who can bind the applicant to the provisions contained in the application, with a clear warning that failure to complete, sign, and return this form with the application may result in the application's rejection.
View the file
Other files for this state and local contract opportunity
| File | Type | Posted |
|---|---|---|
| Appendix G - Business Associate Addendum.pdf | ||
| 25-RFA-13139 HEZ- Addendum 4.pdf | ||
| 25-RFA-13139 HEZ Community Health Care Workers.pdf | ||
| Appendix D - Lobbying Certification and Disclosure.pdf | ||
| 25-RFA-13139 HEZ- Addendum 3.pdf | ||
| Appendix E - Worker Protection and Investment Certification Form.pdf | ||
| Appendix F - Standard Grant Terms and Conditions, DHS Addendum to Terms and Conditions, Audit Clause D.pdf | ||
| 25-RFA-13139 HEZ - Addendum 1.pdf | ||
| 25-RFA-13139 HEZ- Addendum 5.pdf | ||
| Appendix B - Cost Reimbursement Cost Submittal.xlsx | XLSX spreadsheet | |
| Appendix C - Trade Secret Confidential Proprietary Information Notice Form.pdf | ||
| 25-RFA-13139 HEZ - Addendum 2.pdf |
Show all 12
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Text version
APPENDIX A - Application Cover Letter
APPENDIX A
APPLICATION COVER SHEET
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF HUMAN SERVICES
25-RFA-13139
Enclosed in two separate submittals is the application of the Applicant identified below for the above-referenced RFA:
Applicant Information:
Applicant Name
Applicant Mailing Address
Applicant Website Applicant Contact Person Contact Person’s Phone Number Contact Person’s Facsimile Number Contact Person’s E-Mail Address Organization Type � For Profit � Not-For-Profit � Local Government
� Other – Please explain Applicant Federal ID Number Applicant SAP/SRM Vendor Number Applicant Unique Entity Identifier
Submittals Enclosed:
� Technical Submittal
� Cost Reimbursement Cost Submittal
Signature
Signature of an official authorized to bind the Applicant to the provisions contained in the Applicant’s application:
Printed Name Title
FAILURE TO COMPLETE, SIGN AND RETURN THIS FORM WITH THE APPLICANT’S
APPLICATION MAY RESULT IN THE REJECTION OF THE APPLICANT’S APPLICATION.
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