Attach C1 BidderResponse 10-20.docx

ATTACHMENT C1 - BIDDER RESPONSE TEMPLATE

ADMINISTRATIVE REQUIREMENTS RESPONSE (Pass/Fail)

RFP # 27-DCYF-PPS-109

Public Health Nurse

Instructions: Bidders must complete this template and attach the PDF to their emailed RFP Response. Please thoroughly read all instructions in the RFP before completing. All mandatory information must be provided in order to be responsive. Bidder may provide additional documentation as an additional Attachment; the documentation should be specified in this form. Also, please write your Business Name on the bottom of each page of this Response Template.

ADMINISTRATIVE REQUIREMENTS

Bidder Information:

Business Name:

Address:

Telephone:

Email of Legal Entity or Individual:

|_|No

Federal Tax Identifier Number:

WA State Uniform Business Identifier (UBI) Number:

Unique Entity Identifier (UEI) number:

Key Personnel- Identify the key personnel, you will utilize in performing this Contract, and their experience and qualifications.

|_|No |_|N/A

Contract History:

Has the Bidder’s performance on any contract unsatisfactory and resulted in a contract termination in the past five (5) years?

|_|Yes |_|No

If yes, provide a list of those contracts terminated, and include the following:

· Other party’s Name

· Address

· Telephone Number

· Description of the Incident

· Bidder’s Position on the matter

State of Washington Employee(s):

If yes, provide the following information for each individual:

· Name

· Employing Agency

· Job Title while with the Agency

· Separation Date

Bidder’s Exceptions:

If no, please list Bidders exception to the sample contract and general terms and conditions.

Insurance Requirements:

Proprietary or Confidential Information:

If applicable, identify the Sections of the Response which the Bidder considers “Proprietary” or “Confidential” information:

(Optional) OMWBE Certification:

Is Bidder or Bidder’s subcontractor OMWBE Certified?

|_|Yes

If yes, OMWBE Certification # ______________;

If Subcontractor is OMWBE Certified, Subcontractor’s Name ____________________

(Optional) Veteran Owned Business:

Is Bidder or Bidder’s subcontractor certified Veteran Owned Business?

|_|Yes

If yes, DVA Certification # ______________;

If Subcontractor is DVA Certified, Subcontractor’s Name ____________________

(Optional) Small Business:

|_|No |_|If yes, please be sure to sign and return Attachment B.1 Small Business Self-Certifications as part of your proposal.

If Subcontractor(s) is a self-certified Washington Small Business, Subcontractor(s) names:

If yes, please be sure return a sign Attachment B.1 Small Business Self-Certifications for each subcontractor as part of your proposal.

Checklist of Mandatory Response Attachments:

|_|Completed and sign Bidders Certification and Assurances Form (Attachment B)

|_|Complete and sign Small Business Self Certifications, If applicable (Attachment B1)

|_|Completed Administrative Response (Attachment C1; this document)

|_|Completed Technical and Management Response (Attachment C2)

|_|Completed Cost Proposal (Attachment C3)

|_|Diverse Business Inclusion Plan-Subcontractors (Attachment D)

Page 4 of 4 RFP # 27-DCYF-PPS-109