Attachment A VENDOR QUALIFICATIONS CERTIFICATION .docx

COMMUNICATIONS AND ADVERTISING SERVICES FOR MEDICAID OUTREACH

VENDOR QUALIFICATIONS CERTIFICATION

ATTACHMENT A

26-478HFS-DIREC-B-51797

AGENCY CONTRACT NUMBER: 2026-00-025

(FACT-PASS / RESPONSIVENESS ONLY)

SECTION A – VENDOR IDENTIFICATION (FACTUAL - Section 1.5.1 and 1.5.3 and any other applicable provisions of this Contract relating to these requirements) Vendor Legal Name: ______________________________ Year Entity Was Established (MM/YYYY): ______________________________

SECTION B – CONTINUOUS OPERATION (PASS / FAIL REQUIREMENT - Section 1.5.1 and 1.5.3 and any other applicable provisions of this Contract relating to these requirements) Check one box only:

☐ The Vendor has been in continuous operation providing communications and advertising services for at least five (5) consecutive years immediately preceding the Bid opening date , either under its current legal entity or a legally continuous predecessor entity.

☐ The Vendor does not meet this requirement.

If the Vendor has had a legal name change or legal reorganization during the five-year period, list only factual details below (no narrative):

· Former legal name(s): ______________________________

· Effective date(s) of change: ______________________________

SECTION C – PUBLIC SECTOR CAMPAIGN EXPERIENCE

(PASS / FAIL REQUIREMENT – Section 1.5.4 and 1.5.6 and any other applicable provisions of this Contract relating to these requirements) The Vendor must list at least three (3) qualifying campaigns.

Each listed campaign must meet all three criteria identified in Section D below to count.

Campaign Experience Table (FACTUAL ONLY) Limit each entry to brief factual information to identify the campaign

Public Sector Or Government Client (Name)

Entity Type Campaign Start Date

(MM/YYYY)

☐ Federal ☐ State ☐ Local

☐ Statewide ☐Multi-Regional ☐ Yes ☐ No ☐ Yes ☐ No

☐ Federal

☐ Statewide

☐ Yes ☐ No ☐ Yes ☐ No

☐ Federal

☐ Statewide

☐ Yes ☐ No ☐ Yes ☐ No

SECTION D – PRIME CONTRACTOR & ENTITY-LEVEL CERTIFICATION

(FACT-PASS - Section 1.5.4 and 1.5.6 and any other applicable provisions of this Contract relating to these requirements) Check all boxes to be responsive:

☐ All campaigns listed in Section C were performed by the bidding Vendor entity as the prime contractor.

☐ No campaign listed is based solely on the prior work history of individual employees while employed by another firm.

☐ No campaign listed is based solely on subcontractor, affiliate, or parent-entity experience unless performed by a legally continuous predecessor entity of the Vendor.

SECTION E – CERTIFICATION AND ACKNOWLEDGMENT

By signing below, the Vendor certifies and attests that:

1. All information provided in this Attachment A is true, accurate, and complete;

2. The requirements addressed herein are mandatory responsiveness requirements of the IFB;

3. The Agency will make a pass/fail determination based on the information submitted and factual verification using publicly available or other reliable sources; and

4. Failure to meet any requirement or submission of false or misleading information shall render the bid non-responsive.

Authorized Signatory Name: ______________________________ Title: ______________________________ Signature: ______________________________ Date: ______________________________ Top of Form Bottom of Form image1.png