Attachment A Contact Information Cover Sheet.docx

Attachment A Contact Information Cover Sheet Request for Proposals SFGOV- 0000012046 Radiology Registry All fields are required. This form must be completed and included with Electronic File #2.

Proposer Information Legal Name of Company (Proposer): Click or tap here to enter text.

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: Click or tap here to enter text.

Federal Employee Identification Number: Click or tap here to enter text.

California Business Entity Number: Click or tap here to enter text.

City Supplier ID (if registered): Click or tap here to enter text.

Telephone: Click or tap here to enter text.

Cell Phone: Click or tap here to enter text.

Fax: Click or tap here to enter text.

Contact Person: Click or tap here to enter text.

Email Address: Click or tap here to enter text.

Certification of Authority 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.

Authorized Representative’s Printed Name: Click or tap here to enter text.

Authorized Representative’s Title: Click or tap here to enter text.

Date: Click or tap here to enter text.

Authorized Representative’s Signature:

Business Type The following information relates to the legal contractor listed above, whether an individual or a company. If successful, the contract language should refer to me/my company as (select one):

☐ An individual ☐ A partnership. Partners' names: Click or tap here to enter text.

☐ A company ☐ A non-profit. Fiscal Sponsor's name (if applicable): Click or tap here to enter text.

☐ A corporation. If a corporation, organized in the state of: Click or tap here to enter text.

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 to perform the work and to operate as a business in the State of California and the City and County of San Francisco. Please check the item below; failure to check the item may result in the Proposal being deemed non-responsive.

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

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 all items below; failure to check all items may result in the Proposal being deemed non-responsive.

☐ 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 For more information about the MCO, please visit the MCO website. 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 For more information about the HCAO, please visit the HCAO website. 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 HCAO requirements.

3. Health Care Security Ordinance (HCSO) For more information about HCSO, please visit the HCSO website.

4. First Source Hiring Form (FSH) – select one option For more information about FSH, please visit the FSH Program website.

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

Addendum Number(s) Acknowledged: Click or tap here to enter text.