Appendix A.docx

COVER SHEET

Agency or Name:

Mailing Address:

City, State, and Zip Code:

Telephone Number: Fax Number:

Name & Title of Contact Person:

Telephone Number: Fax Number:

Email Address:

1. Indicate which category below Offeror is interested in applying. For a brief description and sample list of programs per category refer to RFSQ section I.A.3. The County intends to create one (1) Qualified Pool (QP) list per each category listed below. From each QP list, the County will identify a single or multiple Offerors to contract with for the purposes of providing program evaluation services.

Select all that apply.

2. Indicate geographic locations where Offeror’s services would be provided in Santa Clara County.

Select all that apply.

☐ Central (San Jose, Milpitas, Santa Clara, Sunnyvale, Saratoga, Cupertino) ☐ Eastern (San Jose) ☐ Northern (Los Gatos, Palo Alto, Los Altos, Mountain View) ☐ Southern (Morgan Hill, San Martin, Gilroy)

3. Indicate experience providing evaluator services to the target populations as described in Attachment A, Scope of Work.

Select all that apply.

Santa Clara County –Behavioral Health Services Department RFP-BHS-FYXX-XXXX: RFP Title

APPENDIX A

County of Santa Clara RFSQ-BHS-FY24-0084: Program Evaluator Services

☐ Children/Youth (ages 0-15) ☐ Transitional Age Youth (ages 16-25) ☐ Adult (ages 26-59) ☐ Older Adult (age 60+)

4. Offeror understands, agrees, and warrants:

A. That Offeror has carefully read and fully understands the information that was provided by the County to serve as the basis for submission of this response;

B. That Offeror has the capability to successfully undertake and complete the responsibilities and obligations of the response being submitted;

C. That all information contained in the response is true and correct to the best of Offeror’s knowledge;

D. That Offeror signed a non-collusion affidavit herewith attached with the response;

E. That Offeror did not receive unauthorized information from any County staff or consultant during the response period except as provided for in the RFSQ packet, addenda thereto, or the pre-proposal conference;

F. That by submission of this response, the Offeror acknowledges that the County has the right to make any inquiry it deems appropriate to substantiate or supplement information supplied by the Offeror, and Offeror hereby grants the County permission to make said inquiries, and to provide any and all requested documentation in a timely manner; and

G. That Offeror offers and agrees to furnish the goods and services specified in the response.

No response shall be accepted which has not been signed in ink in the appropriate space below.

I hereby certify that I am an authorized representative of the above agency and to the best of my knowledge and belief that:

The data in this response is true and accurate; the Offeror has investigated all aspects of the RFSQ; the Offeror is aware of the applicable facts pertaining to the RFSQ process, procedures, and requirements; the Offeror has read and understands the RFSQ; the Offeror has the capability to successfully undertake and complete the responsibilities and obligations of their response being submitted; the agency will be able to meet all of the minimum response requirements as specified in this RFSQ; and the Offeror will comply with the necessary certifications and assurances if a contract is awarded.

This shall constitute a warranty, the falsity of which entitles the County to pursue any remedy authorized by law, including the right to declare any contract made as a result thereof to be void.

By signing below, the submission of a response shall be deemed a representation and certification by the Offeror that it has investigated all aspects of the RFSQ; that it is aware of the applicable facts pertaining to the RFSQ process, its procedures and requirements; and that it has read and understands the RFSQ. No request for modification of the response shall be considered after its submission on the grounds that the Offeror was not fully informed as to any fact or condition.

1. If Offeror is an INDIVIDUAL, sign here:

Date Offeror’s Signature

Offeror's Name and Title (Type or Print)

2. If Offeror is a CORPORATION, the duly authorized officer(s) shall sign here:

The undersigned certify they are respectively:

and

Title

Title of the CORPORATION named below; they are designated to sign this response form by resolution or by the Secretary of State's certificate of authorization, for and on behalf of the below named CORPORATION, and they are authorized to execute same for and on behalf of said CORPORATION.

Corporation Name (Type or Print)

By:

Date:

Title:

By:

Date:

Title: