Attachment A-Application.pdf

Request for Application (RFA)

OREGONBUYS NUMBER S-10000-00010733/ODHS-RFA-5903

Attachment A

Application Form

Applicants must comply with and meet the requirements of the RFA and submit this completed Application Packet along with all required information to be considered for a Contract.

Application for Oregon Department of Human Services (ODHS)

Aging and People with Disabilities

SENIOR EMERGENCY MEDICAL SERVICES PILOT PROJECTS

Section 1: General Applicant Information (Click in each grey area and begin typing)

Applicant Name/Organization Name:

Mailing Address:

City: State: County: Zip Code:

Office Phone:

Cell Phone:

Contact Name and Title:

Address (if different than above):

City: State: County: Zip Code:

Email:

Section 2: Responsible Applicant Requirements (Double click and check applicable box)

BUSINESS REGISTRY

Yes, Applicant is currently registered with the Oregon Secretary of State business registry.

No, Applicant is not currently registered with the Oregon Secretary of State business registry but will meet requirement prior to Contract execution.

INSURANCE

Commercial General Liability (CGL) Insurance:

Yes, we currently meet the CGL insurance requirement.

No, we do not currently meet CGL insurance requirements but will meet requirement prior to Contract execution.

Attachment A

Section 3: Applicant Program Type (Double click and check each box applying for)

Is Applicant a Public Service Entity; or

Is Applicant qualified to provide public services

Program Service Types:

Innovative strategies for addressing the emergency medical services needs if this state's increasing number of aging residents who receive care and services in residential care facilities and long-term care facilities;

Efficient and appropriate use of senior emergency medical services;

Reduction of the overall costs of senior emergency medical services while promoting quality emergency medical services; or

Unique community-based responses to challenges faced by local communities in meeting their residents' needs for senior emergency medical services.

Section 4: Applicant Checklist (Double click and check each box)

APPLICATION PACKET (Attachment A)

Yes, Applicant has completed all sections of this Application Packet in its entirety and signed below (Attachment A).

RESPONSIBILITY INQUIRY

Yes, Applicant has attached completed Responsibility Inquiry per RFA Section 3.2.4 (Attachment C).

COBID OUTREACH PLAN

Yes, Applicant is a COBID Certified as per section 3.2.5 of the RFA.

No, Applicant is NOT a COBID Certified as per section 3.2.5 of the RFA.

APPLICATION RESPONSE

Yes, Applicant has attached a complete response to section 3.3 of the RFA.

AMOUNT ASKING FOR

Yes, Applicant has attached the amount Applicant is asking for.

Attachment A

Applicant Signature (Click in each grey area and begin typing)

By signing below, Applicant certifies they have read the following and understands the RFA they have applied for. Applicant certifies qualifications, ability, and availability to provide the services described in this RFA and outlined in the Application Packet submitted in response to this RFA.

1. Applicant understands and accepts the requirements of RFA S-10000-00010733. By submitting this Application, Applicant agrees to be bound by the

Contract terms and conditions in Attachment B and as modified by any Addenda, except for those terms and conditions that Agency has reserved for negotiation as identified in RFA S-10000-00010733.

2. Applicant acknowledges receipt of any and all Addenda to RFA S-10000-00010733.

3. I have knowledge regarding Applicant’s payment of taxes and by signing below I hereby certify that, to the best of my knowledge, Applicant is not in violation of any tax laws of the state or a political subdivision of the state, including, without limitation, ORS 305.620, and ORS chapters 316, 317 and

318.

4. Applicant and Applicant’s employees, agents, and subcontractors are not included on:

a. the “Specially Designated Nationals and Blocked Persons” list maintained by the Office of Foreign Assets Control of the United States Department of the Treasury found at: https://www.treasury.gov/ofac/downloads/sdnlist.pdf, or

b. the government wide exclusions list in the System for Award Management found at: https://www.sam.gov/portal/.

5. Applicant certifies that, to the best of its knowledge, there exists no actual or potential conflict between the business or economic interests of Applicant, its employees, or its agents, on the one hand, and the business or economic interests of the State, on the other hand, arising out of, or relating in any way to, the subject matter of the RFA. If any changes occur with respect to Applicant’s status regarding conflict of interest, Applicant shall promptly notify the

State in writing.

6. Applicant certifies that, all contents of the Application (including any other forms or documentation, if required under RFA S-10000-00010733) are truthful and accurate and have been prepared independently from all other Applicants, and without collusion, fraud, or other dishonesty.

7. Applicant understands that any statement or representation it makes, in response to RFA S-10000-00010733, if determined to be false or fraudulent, a misrepresentation, or inaccurate because of the omission of material information could result in a “claim” {as defined by the Oregon False Claims Act, ORS 180.750(1)} made under Agreement being a “false claim” {ORS 180.750(2)} subject to the Oregon False Claims Act, ORS 180.750 to 180.785, and to any liabilities or penalties associated with the making of a false claim under that Act.

8. Applicant acknowledges these certifications are in addition to any certifications required in the Contract and Program Description in Attachment B at the time of Contract execution.

9. Applicant has read and is familiar with the provisions of Oregon’s Public Records Law, Oregon Revised Statutes (“ORS”) 192.311 through 192.478, and the Uniform Trade Secrets Act as adopted by the State of Oregon, which is set forth in ORS 646.461 through 646.475. Applicant understands that the

Application is a public record held by a public body and is subject to disclosure under the Oregon Public Records Law unless specifically exempt from disclosure under that law. Applicant acknowledges this Application is not exempt from disclosure.

Applicant Signature (Click in each grey area and begin typing)

Name and Title:

Phone:

Email:

Authorized Signature:

https://www.treasury.gov/ofac/downloads/sdnlist.pdf https://www.sam.gov/portal/