Attachment 1 Proposal Information Form~1.docx
DOCX document 46 KB Posted
- Solicitation number
- S-44300-00015624
- Issued by
- Lane County, Oregon
About this file
This is a Proposal Information Form for the Oral Health Workforce Expansion Funding Grant Opportunity administered by the State of Oregon. The form serves as the initial submission document for organizations seeking grant funding to address oral health workforce needs. Proposers must submit a Project Abstract Summary of no more than 500 words that describes the proposed project, including the target workforce need, goals, objectives, and outcomes. The abstract may be published on the Oral Health Grant Program website and in other online and hard-copy publications if the organization is awarded funding. The form requires organizations to provide basic information including organization name, doing business as name, fiscal sponsor information, contact details, and a project abstract that will form the basis for the proposal summary in grants management and program summary documents.
Eligible proposers must meet specific organizational and insurance requirements prior to contract execution. Organizations must be registered with the Oregon Secretary of State Business Registry or commit to meeting this requirement before agreement execution. Proposers must also demonstrate compliance with Commercial General Liability Insurance and may need to obtain Professional Liability Insurance and Automobile Liability Insurance depending on project requirements, with attestations confirming current compliance or commitment to compliance before contract execution. An authorized legal representative must sign the attestation form, certifying that all information provided is true and accurate and affirming the organization's non-discrimination policy in accordance with state and federal guidelines.
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Other files
| File | Type | Posted |
|---|---|---|
| Attachment 2 Sample Grant Agreement~1.pdf | ||
| S-44300-00015624 Teledentistry Expansion Grant Opportunity Notice~1.pdf | ||
| Attachment 3 Teledentistry Budget Table.xlsx | XLSX spreadsheet | |
| Year 4 NOA with Carryover.PDF |
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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 Proposer.
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 .