Appendix K.docx
DOCX document 31 KB Posted
- Attached to
- Behavioral Health Training Services
- Solicitation number
- RFSQ-BHS-FY25-0176
- Issued by
- California
About this file
This is an Offeror's FEIN and License Information Form for the County of Santa Clara Behavioral Health Services Department's Request for Statement of Qualifications (RFSQ-BHS-FY25-0176) for Behavioral Health Training Services. The County Health System is seeking qualified and experienced firms to provide health and professional training services supporting County clinical staff and County-contracted Provider staff. Offerors must submit complete and accurate information in response to this RFSQ, with any omissions, inaccuracies, or misstatements potentially resulting in rejection of the response.
The form requires offerors to provide their legal name and Federal Employer Identification Number (FEIN), business name as registered with the California Secretary of State, and relevant professional and facility licenses. Specifically, offerors must disclose whether they hold licenses from the Medical Board of California, the Board of Behavioral Sciences, or certifications as Care Facility Providers through the California Department of Social Services, Substance Use Treatment Facility Providers through the California Department of Health Care Services, or Healthcare Facility Providers through the California Department of Public Health. All responses must be submitted under penalty of perjury, with offerors certifying the accuracy and truthfulness of all statements, answers, and representations provided on the form.
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Other files
| File | Type | Posted |
|---|---|---|
| Solicitation_Document_1.pdf | ||
| Solicitation_Document.pdf | ||
| Appendix J.docx | DOCX document | |
| Addendum 1.pdf | ||
| Appendix E.docx | DOCX document | |
| Appendix B.docx | DOCX document | |
| Appendix F.docx | DOCX document | |
| Attachment E.pdf | ||
| Appendix I.doc | DOC document | |
| Appendix H.docx | DOCX document | |
| Attachment B.pdf | ||
| Attachment D.pdf | ||
| Appendix C.docx | DOCX document | |
| RFSQ-BHS-FY25-0176.pdf | ||
| Attachment C.pdf | ||
| Appendix G.docx | DOCX document | |
| Addendum 2.pdf | ||
| Attachment A.pdf | ||
| Appendix A.docx | DOCX document | |
| Appendix D.docx | DOCX document |
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Text version
APPENDIX K
County of Santa Clara – Behavioral Health Services Department RFSQ-BHS-FY25-0176: Behavioral Health Training Services
OFFEROR’S FEIN AND LICENSE INFORMATION FORM
All information requested in the Form shall be furnished by the Offeror and shall be submitted with the response to this Request for Statement of Qualifications (RFSQ). Information shall be complete, accurate, and in the form requested. Any omissions, inaccuracies, or misstatements may be cause for the rejection of a response in whole or part.
1. Legal name and Federal Employer Identification Number (FEIN) of Offeror exactly as it appears on the W9 (include DBA, if applicable): ___________________________________________________________
2. What is your business name under the California Secretary of State: ___________________________________________________________
3. Do you have a license with the Medical Board of California?
☐ Yes License Type: _________________________ License Number: _______________________ ☐ No, I am an individual without a license with the Medical Board of California ☐ Not applicable (contracting with an organization)
4. Do you have a license with the Board of Behavioral Sciences?
☐ Yes License Number: ________________________ ☐ No, I am an individual without a license with the Board of Behavioral Sciences ☐ Not applicable (contracting with an organization)
5. Are you a Care Facility Provider (licensed through the California Department of Social Services)?
☐ Yes Facility Number (must contain 9 digits): ________________________ Licensed Bed Count: ________________________________________ ☐ No
6. Are you a Substance Use Treatment Facility Provider (licensed or certified by California Department of Health Care Services)?
☐ Yes License/Certification Type: ________________________________ License Status: _________________________________________ Licensed Bed Count: _____________________________________ ☐ No
7. Are you a Healthcare Facility Provider (licensed through the California Department of Public Health)?
☐ Yes License Number: ___________________________ License Facility ID: __________________________ License Status: ____________________________ Licensed Bed Count: ________________________ ☐ No
The undersigned hereby declares under penalty of perjury that all statements, answers and representations made in this form are true and accurate.
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Last Reviewed and Approved by Counsel on 12/04/2024
File details come from the government source that posted it. Updated .