attachment_4_-_proposal-proposer_certification_sheet.pdf

RFP 27-3001 Attachment 4 California Department of Social Services Page 1 of 4

PROPOSAL / PROPOSER CERTIFICATION SHEET

This Proposer / Proposer Certification Sheet must be signed and returned along with all the “required attachments” as an entire package with original signatures. The proposal must be transmitted in a sealed envelope in accordance with RFP instructions.

A. Place all required attachments behind this certification sheet.

B. I have read and understand the DVBE Participation requirements and have included documentation demonstrating that I have met the participation goals.

C. The signature affixed hereon and dated certifies compliance with all the requirements of this proposal document. The signature below authorizes the verification of this certification.

NOTE: An unsigned Proposal / Proposer Certification Sheet may be cause for rejection

1. Company Name: ____________________________________________________

2. Telephone Number: __________________________________________________

3. Fax Number: _______________________________________________________

4. Email Address: ______________________________________________________

5. Address: ___________________________________________________________

6. Indicate your organization type: Sole Proprietorship Partnership Corporation

7. Indicate the applicable employee and/or corporation number:

a. Federal Employee ID No. (FEIN): __________________________________

b. California Corporation No.: _______________________________________

8. Indicate applicable license and/or certification information: ____________________

9. Bidder’s Name (Print): _________________________________________________

10. Title: ______________________________________________________________

11. Signature: _____________________________________ 12. Date: _____________

13. Are you certified with the Department of General Services, Office of Small Business and Disabled Veteran Business Enterprise Services (OSDS) as:

a. California Small Business Yes No

If yes, enter certification number: __________________________________

California Department of Social Services Page 2 of 4

b. Disabled Veteran Business Enterprise Yes No

If yes, enter your service code: ____________________________________

NOTE: A copy of your Certification is required to be included if either of the above items is checked “Yes.”

If an application is pending, include date application was submitted to OSDS: _____

California Department of Social Services Page 3 of 4

Completion Instructions for Proposal / Proposer Certification Sheet

Complete the numbered items on the Proposal / Proposer Sheet by following the instructions:

Item Numbers

Instructions

1, 2, 3, 4, 5

Must be completed. These items are self-explanatory.

Check if your firm is a sole proprietorship, a partnership, or a corporation.

A sole proprietorship is a form of business in which one person owns all the assets of the business in contracts to a partnership and corporation. The sole proprietorship is solely liable for all the debts of the business.

A partnership is a voluntary agreement between two (2) or more competent persons to place their money, effects, labor, and skill or some or all of them in lawful commerce or business, with the understanding that there shall be a proportional sharing of the profits and losses between them. An association of two or more persons to carry on, as co-owners, a business for profit.

A corporation is an artificial person or legal entity created by or under the authority of the laws of a state or nation, composed, in some rare instances, of a single person and his successors, being the incumbents of a particular office, but ordinarily consisting of an association of numerous individuals.

7a

Enter your federal employee tax identification number.

7b

Enter your corporation number assigned by the California Secretary of State’s Office. This information is used for checking if a corporation is in good standing and qualified to conduct business in California.

Complete, if applicable, by indicating the type of license and/or certification that your firm possesses and that is required for the type of services being procured.

California Department of Social Services Page 4 of 4

9, 10, 11, 12

Must be completed. These items are self-explanatory.

If certified as a California Small Business, place a check in the “Yes” box, and enter your certification number on the line. If certified as a Disabled Veterans Business Enterprise, place a check in the “Yes” box and enter your service code on the line. If you are not certified to one or both place a check in the “No” box. If your certification is pending, enter the date your application was submitted to OSDS.