Attachment A- Application Form-REQUIRED With Submission.pdf
PDF 207 KB Posted
- Attached to
- MDAR- Master List for Veterinary Services-FY21
- Solicitation number
- BD-21-1002-1003-001-62822
- Issued by
- Suffolk County, Massachusetts
About this file
The document is an Application Form required for submission under a Request for Response (RFR) issued by the Department of Agricultural Resources, Division of Animal Health in Massachusetts. The RFR is seeking qualified veterinarians with experience in large animal, small animal, or avian/poultry care to establish a Master Contract and create a list of vendors that the Department can utilize to meet its program needs. Applicants must provide information on their licensing, areas of practice, and the specific services they are willing to provide, which include Routine Services, Specialized Services, and Emergency Services. The RFR allows for both single and multi-veterinary practice submissions, requiring details on all participating veterinarians.
The RFR does not provide specifics on pricing terms, set-asides, incumbent information, funding requirements, or other salient commercial details. It focuses solely on establishing a qualified vendor list for the Department of Agricultural Resources, Division of Animal Health in Massachusetts to utilize as needed for their veterinary service requirements.
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Text version
REQUEST FOR RESPONSE
AGR-VeterinaryServices-FY21
DEPARTMENT OF ANIMAL HEALTH
PARTICIPATING VETERINARIAN APPLICATION
Attachment A: REQUIRED with Submission
Date:
Legal/Business Name:
DBA:
Address
Town, State, Zip
Email: Phone:
Please Complete the qualifications that apply:
Massachusetts-licensed, current and in good standing: Yes No Private practice large animal work (state # of years):
Private practice small animal work (state # of years):
Private practice poultry (state # of years):
Shelter Medicine Work? (state # of years) Previously contracted for this work with the Department: Yes No
Please check off the Services you would like to respond to:
A. Routine Services B. Specialized Services C. Emergency Services
For SINGLE or MULTI-VETERINARY PRACTICES, please name all individual veterinarians and license numbers and check off what Services they are willing to perform:
Name
License #
Federally Accredited?
Y/N
SERVICES:
Routine Specialized Emergency
Signature:
Date:
Print Name:
Title:
AGR-VeterinaryServices-FY21, Rev- 02-02-2024.docx
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| Private practice poultry state of years: |
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| License 1: |
| Federally Accredited YN1: |
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