Attachment 1 Proposal Information Form.docx
DOCX document 46 KB Posted
- Attached to
- RFGP Jackson County Mobile Dental Van Expansion
- Solicitation number
- S-44300-00015052
- Issued by
- Jackson County, Oregon
About this file
This is a Proposal Information Form for the Oral Health Workforce Expansion Funding Grant Opportunity administered by the Oregon Health Authority (OHA) in Jackson County. The form serves as the application submission document for organizations seeking to participate in a Mobile Dental Van Expansion program designed to eliminate health disparities and expand oral health care access to underserved populations. Applicants must complete organizational information including entity name, doing-business-as name, fiscal sponsor details, and contact information. The form requires submission of a Project Abstract Summary not exceeding 500 words that describes the proposed project, identifies target workforce needs, and outlines goals, objectives, and outcomes. If awarded, the abstract may be published on the Oral Health Grant Program website and in other publications.
Applicants must demonstrate compliance with specific insurance and registration requirements prior to contract execution, including Commercial General Liability Insurance, Professional Liability Insurance if required, and Automobile Liability Insurance if required. Organizations must be registered with the Oregon Secretary of State Business Registry or commit to meeting this requirement before agreement execution. The form includes an attestation section requiring a legally authorized representative to certify the accuracy of submitted information and confirm that the organization does not discriminate against any group recognized under state and federal non-discrimination guidelines. The signer must provide their name, title, signature, date, email address, and phone number as part of the formal submission.
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Text version
Oral Health Workforce Expansion Funding Grant OpportunityAttachment 1
Proposal Information Form Organization name:
Organization doing business as (dba)
Fiscal sponsor Organization (if applicable):
Organization address:
Contact name:
Contact email:
Contact phone number:
Registered with the Secretary of State ________ Yes, Proposer is currently registered with the Oregon Secretary of State Business Registry. _________ Provide Registry Number
_________ No, Proposer is not currently registered with the Oregon Secretary of State business registry but will meet requirement prior to Agreement execution.
Commercial General Liability Insurance (CGL) ________ Yes, we currently meet the CGL License insurance requirement ________ Does not currently meet CGL insurance requirements and will meet requirement prior to Contract execution.
Professional Liability Insurance (PLI) if required _______ Yes, we currently meet the PLI insurance requirement.
_______ Do not currently meet PLI insurance requirements but will meet requirement prior to Contract execution.
Automobile Liability Insurance (ALI) if required _______ Yes, we currently meet the ALI insurance requirement.
_______ Do not currently meet ALI insurance requirements but will meet requirement prior to Contract execution.
OB S-44300-00015052 Page 1 Oral Health Workforce Expansion Funding Grant Opportunity Project Abstract Summary (500-word limit) The Project Abstract Summary will be used to provide reviewers with an overview of the proposal and will form the basis for the proposal summary in grants management and program summary documents. Abstract should include a brief description of the proposed project, including target workforce need, goal(s), objectives, and outcomes. If your organization is awarded, the Abstract may be published on the Oral Health Grant Program website and in other online and hard-copy publications.
Add your project abstract summary below (no more than 500 words):
Attestation A legal representative from your organization must initial the following applicable assurances:
We do not discriminate against any group recognized under state and/or federal guidelines for non-discrimination. ( ) The individual signing below hereby certifies they are an authorized representative of the Applicant.
By signing below, I attest that the information, data, and answers contained in this attestation are true and accurate to the best of my knowledge.
| Name: __________________________ | Title: ______________________ |
| Signature: _______________________ | Date: ____________ |
Email address of signer: _________________________________ Phone number of signer: ________________________________ image1.png
File details come from the government source that posted it. Updated .