Att 1 - Submittal Form A Offeror Information and Certifications.docx

State of Alaska RFP Proposal Submittal Form A

STATE OF ALASKA

SUBMITTAL FORM A

PROPOSAL COVER SHEET

PROJECT INFORMATION AND OFFEROR INFORMATION

RFP Number

RFP Project Name

Company Name

Address

Tax ID #

Alaska Business License #

OFFEROR CONTACT INFORMATION:

Provide contact information for the individual that can be contacted for clarification regarding this proposal. This proposal must be signed by a company officer empowered to bind the company.

Printed Name

Signature

Date:

Title

Address

Email

Phone:

CRITICAL TEAM MEMBERS

Provide the names of all critical team members that will be assigned to this contract. Note: These individuals cannot be removed or replaced from this project, or their positions, unless approved in writing by the project director or procurement officer. Insert rows if needed.

Account Manager

Implementation Manager

Clinical Pharmacist

Member Services Manager

Medicare Part D/EGWP Expert

AMENDMENT ACKNOWLEDGEMENT

The offeror acknowledges receipt of the following amendments and has incorporated the requirements of such amendments into their proposal. Failure to identify and sign for all amendments may subject the offeror to disqualification. The offeror must list all amendments by number and initial and date to confirm that you have received and incorporated them into your proposal. Insert rows if needed.

NOTE: Failure to answer or answering “No” may be grounds for disqualification. For any “No” response, the offeror must provide clarification below. Each clarification may not exceed 250 words. Insert rows if needed.

CONFLICT OF INTEREST STATEMENT

Indicate below whether or not the firm or any individuals that will work on the contract has a possible conflict of interest (e.g., currently employed by the State of Alaska or formerly employed by the State of Alaska within the past two years) and, if so, the nature of that conflict. The procurement officer reserves the right to consider a proposal non-responsive and reject it or cancel the award if any interest disclosed from any source could either give the appearance of a conflict or cause speculation as to the objectivity services to be provided by the offeror.

NOTE: Failure to answer may be grounds for disqualification.

If “Yes”, please provide additional information regarding the nature of that conflict:

FEDERAL REQUIREMENTS

Indicate below all known federal requirements that apply to the proposal, its evaluation, or the resulting contract:

ALASKA PREFERENCES

If you wish to claim any Alaska Preferences, please complete the Alaska Offeror Preference Certification Form that follows the below signature section.

SIGNATURE

This Submittal Form A must be signed on the front page by a company officer empowered to bind the company.

ALASKA OFFEROR PREFERENCE CERTIFICATION FORM

AS 36.30.321(A) / AS 36.30.990(2)

Solicitation Number

Project Description

Business Name

Alaska Business License Number

A signed copy of this form must be included with your proposal or proposal no later than the deadline set for receipt of proposals or proposals.

If you are submitting a proposal or proposal as a JOINT VENTURE, all members of the joint venture must complete and submit this form before the deadline set for receipt of proposals or proposals. AS 36.30.990(2)(E) If the procuring agency is unable to verify a response, the preference may not be applied. Knowingly or intentionally making false or misleading statements on this form, whether it succeeds in deceiving or misleading, constitutes misrepresentation per AS 36.30.687 and may result in criminal penalties.

SIGNATURE

By signature below, I certify under penalty of law that I am a company officer of the above entity and all information on this form is true and correct to the best of my knowledge.

Printed Name:

Title:

Date:

Signature:

To qualify for and claim the Alaska Bidder Preference you must answer YES to all questions in the Alaska Bidder Preference Question section below:

Alaska Bidder Preference Questions

If the answer to question 3 is YES, complete the following:

Physical Place of Business Address

City/State

Zip Code

“Place of business” is defined as a location at which normal business activities are conducted, services are rendered, or goods are made, stored, or processed; a post office box, mail drop, telephone, or answering service does not, by itself, constitute a place of business per 2 AAC 12.990(b)(3).

Per AS 16.05.415(a) and 2AAC 12.990(b)(7), the offeror or offeror, or at least one employee of the offeror or offeror must be a resident of the state?

Per AS 36.30.990(2)(D), is your business:

If yes, enter the current Alaska Corporate Entity Number:

Indicate below how your business is organized:

If the answer to question 2 above is YES, please identify each member by name and state of residence:

If the answer to question 3 above is YES, please identify each partner by name and state of residence:

Alaska Veterans Preference Questions:

To qualify for and claim the Alaska Veteran Preference, you must answer YES to at least one of the following four questions and answer YES to all the questions in the Alaska Bidder Preference section above.

To be eligible for this preference you must be a “qualifying entity” as that term is defined in AS 36.30.321(f)(2).

Is your business a:

OR

Per AS 36.30.321(f)(3), a “veteran” is defined as an individual who:

1. Served in the:

0. Armed forces of the United States, including a reserve unit of the United States armed forces ; or

0. Alaska Territorial Guard, The Alaska Army National Guard, the Alaska Air Nations Guards, or the Alaska Naval Militia; and,

1. Was separated from services under a condition that was not dishonorable.

Alaska Military Skills Program Preference Questions To qualify for and claim the Alaska Military Skills Program Preference, you must answer YES to the below questions as well as answer YES to all the questions in the Alaska Bidder Preference section above.

Per AS 36.30.321(l), does your business:

during the last 180 days before a the person separates or retires from the service?

|_| YES |_| NO

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