Attachment A Contact Information Cover Sheet_1.pdf

ATTACHMENT “A”

CONTACT INFORMATION COVER SHEET

REQUEST FOR PROPOSALS SFGOV-0000011811

HUMAN IMMUNODEFICIENCY VIRUS (HIV) PREVENTION CAPACITY BUILDING

ASSISTANCE PROGRAM ADMINISTRATION SERVICES

*ALL FIELDS ARE REQUIRED. THIS FORM MUST BE COMPLETED AND SUBMITTED

WITH YOUR TECHNICAL/WORK PROPOSAL (ELECTRONIC FILE #1).*

LEGAL NAME OF COMPANY(PROPOSER): ________________________________________

*Legal name must include any “Doing Business As” (DBA). The name provided here must exactly match the name used in all submitted documents.

BUSINESS ADDRESS: _________________________________________________________

FEDERAL EMPLOYEE IDENTIFICATION NUMBER: _________________________________

CALIFORNIA BUSINESS ENTITY NUMBER: _______________________________________

CITY SUPPLIER ID (if registered): ________________________________________________

TELEPHONE: _______________ CELL PHONE: _______________ FAX: ________________

CONTACT PERSON: ____________________ EMAIL ADDRESS: ______________________

A. I hereby certify that I have the authority to submit this Proposal to the City and County of San Francisco for the above listed individual or company. I certify that I have the authority to bind myself/this company in a contract should I be successful in my proposal.

PRINTED NAME TITLE

SIGNATURE DATE

B. The following information relates to the legal contractor listed above, whether an individual or a company. Place check marks as appropriate:

1. If successful, the contract language should refer to me/my company as:

An individual;

A partnership, Partners’ names: ____________________________________

A company;

A non-profit, Fiscal Sponsor’s name (if applicable): __________________________

A corporation, if a corporation, organized in the state of: _________________

C. Representation re Good standing, Licenses, Etc.

A representation that the Proposer is in good standing in the State of California and has all necessary licenses, permits, approvals and authorizations necessary in order to perform the Work and conduct the Candidate’s business. Please check the item below if you agree with this statement.

I hereby represent and certify that the above statement is true and correct.

D. Representation regarding City Contracting Requirements.

A representation that the Proposer is able and willing to comply with all the contracting requirements described in this RFP. Please check the items below if you agree with the statements.

I hereby represent and certify that the Proposer will comply with all contracting requirements, including the City’s Contract Terms, as described in this RFP. The City reserves the right to terminate negotiations with any candidate that does not execute the City’s Contract Terms.

I hereby represent and certify that the Proposer will comply with all San Francisco labor laws for City contractors.

1. Minimum Compensation Ordinance (MCO)

MCO Declaration completed Note: The Declaration is required even if your firm qualifies for an exemption under OLSE’s list of approved exemptions. The MCO applies to all subcontractors, and Proposers are responsible for ensuring that their subcontractors comply with all MCO requirements.

2. Health Care Accountability Ordinance (HCAO) HCAO Declaration completed

Note: The Declaration is required even if your firm qualifies for an exemption under OLSE’s list of approved exemptions. The HCAO applies to all subcontractors, and Proposers are responsible for ensuring that their subcontractors comply with all MCO requirements.

3. Health Care Security Ordinance (HCSO)

4. First Source Hiring Form (FSH) – Select one option.

FSH completed (proof included in Proposal) FSH exception submitted to First Source (proof included in Proposal)

E. ADDENDA ACKNOWLEDGMENT:

Acknowledgment of Receipt of any Addenda issued by the City for this RFP is required by including the acknowledgment with your proposal. Failure to acknowledge the Addenda issued may result in your proposal being deemed non-responsive.

In the space provided below, please acknowledge receipt of each Addenda:

Addendum(s) # _______________ is/are hereby acknowledged.

http://sf.gov/sites/default/files/2024-03/MCO%202015%20List%20of%20Exemptions%20for%20the%20Minimum%20Compensation%20Ordinance-no%20mayor.pdf https://www.sf.gov/sites/default/files/2022-12/9494-HCAO%20List%20of%20Exemptions.pdf