Attachment A 99SWC-S107.docx

RFQ 99SWC-S107

Attachment A

Application Checklist Complete and return this form as part of your submission along with all applicable documentation below:

Applicant

☐ Applicant Name:

☐ Medical Facility Name or Practice Name:

☐ Area of Expertise:

☐ Region / Location of Services:

☐ Application Submission Letter:

☐ State Professional/Medical Certification/ License and any applicable license for the RFQ (Please list all below and attach documentation as proof of certification/licensure.)

a.____________________________________ b.____________________________________ c.____________________________________ d.____________________________________ e.____________________________________ f.____________________________________

□ ☐ Insurance Requirements (Attach COI insurance documents listed on Insurance Schedule.)

☐ Nevada Secretary of State Business License (Attach most recent and valid copy.)

☐ State of Nevada Controller’s Office T# (if Known):

*if T# is unknown please visit the link below to register with Controller for payment of services. http://controller.nv.gov/Buttons/ElectronicVendorReg/ (copy and paste into your browser window)

Signature: __________________________________ Date: ________________

By signing this application, you are acknowledging that the you have read the attached Contract Form and Insurance Schedule, and that both forms are non-negotiable and must be accepted as written in order to be granted a contract with the State of Nevada. By signing this application, you also agree to complete this application in its entirety and that failure to do so may disqualify you or your organization from consideration under this RFQ.