Attachment_B_-_Vendor_Info_Form.pdf
PDF 586 KB Posted
- Attached to
- Emerging Adult Transitional Living Program
- Solicitation number
- 424014-PMW
- Issued by
- Dane County, Wisconsin
About this file
This document is a Vendor Information Form for a Request for Proposal (RFP) issued by Dane County, Wisconsin for the Emerging Adult Transitional Living Program. The form requires potential vendors to provide comprehensive organizational details, including business and fiscal information, board composition, staff demographics, and vendor-specific data. The document includes sections for applicants to attest to their organizational structure, accounting practices, legal status, and compliance with labor standards, and provides spaces to designate confidential information.
The form seeks detailed information about the organization's governance, including board meeting frequency, board member details, and organizational demographics. It includes certification sections for minority, women-owned, and disabled veteran business entities, and requires vendors to disclose any legal proceedings or bankruptcy history. The document also includes provisions for local vendor preferences, cooperative purchasing options, and requires vendors to affirm they have not engaged in collusive bidding practices. Notably, the form emphasizes transparency and requires vendors to potentially identify confidential information while acknowledging that pricing information will always be public.
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Other files
| File | Type | Posted |
|---|---|---|
| Emerging_Adult_Transitional_Living_Program_(Addendum_#2_Revision).pdf | ||
| 424014_-_ABC_COMPANY_Cost_Proposal.xlsx | XLSX spreadsheet | |
| Attachment_C_-_Property_Photos.pdf | ||
| Attachment_A_-_Community_Partnerships.docx | DOCX document |
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Text version
Applicant Summary and Signature Page
Organization legal name:
Mailing address:
(if P.O. Box, include street address)
Telephone:
Fax number:
Name of chief admin/contact:
E-mail address of chief admin:
Website:
Legal status Private Non-Profit Private For-Profit Other (LCC, LLP, Sole Proprietor)
Federal EIN:
RFP number and title:
Contact person:
Contact phone number:
Contact e-mail address:
I hereby attest that all statements made in this application and any attachments are true and correct to the best of my knowledge.
Signature of legal representative/organization head: _____________________________
Title: ____________________________
Printed name: __________________________
Date: ______________________________
Section 1. Applicant Information
Business Information
Date business originally established:
Number of years under current ownership:
How many years have you been doing business under your present firm or trade name?
Please list other names under which this business may have operated:
Fiscal Information
If you are working with an accounting firm to handle fiscal operations, how long have you worked with this firm?
Provide the following information on the employees in your organization who will have primary fiscal responsibilities such as billing and claiming, payroll, etc.
Name Job Title % of time spent per week on fiscal duties
If less than 100%, describe other duties
Please provide information on the accounting/auditing practices of your organization. Please note that this information is not scored.
a. Agency maintains accounting records in accordance with the Generally Accepted Accounting Principles (GAAP). GAAP is the general guidelines and principles, standards and detailed rules, plus industry practices that exist for financial reporting.
If you are unsure or you do not know, please check No.
Yes No
b. Agency maintains a uniform double entry accounting system which is compatible with cost accounting and generally accepted accounting principles.
Yes No
c. Agency maintains a cost allocation plan with costs allocated in a manner consistent with these plans.
Yes No
d. Agency audit is performed annually by an independent, outside party in accordance with generally accepted auditing standards.
Yes No
e. Has the most recent audit revealed any significant or ongoing concerns? Yes
Legal Information Please attach a detailed explanation for any YES responses below.
Has the applicant or any owner been involved in any lawsuits or judgements in the last five (5) years or have any lawsuits pending?
Has the applicant or any owner been involved in any bankruptcy or insolvency proceedings or have any proceedings pending?
Section 2: Agency Governing Board
a. How many Board meetings has your governing board or Board of Directors scheduled for the current calendar year?
b. How many meetings were held in the prior calendar year?
Please list your current Board of Directors or you agency’s governing body. Include name, address, primary occupation, term information, and board office held.
Board President’s Name Contact Address Contact E-mail Occupation Representing Current Term of Office from __ to __ Total Years of Service
Board Vice-President’s Name Contact Address Contact E-mail Occupation Representing Current Term of Office from __ to __ Total Years of Service
Board Secretary’s Name Contact Address Contact E-mail Occupation Representing Current Term of Office from __ to __ Total Years of Service
Board Treasurer’s Name Contact Address Contact E-mail Occupation Representing Current Term of Office
Board Member Name Contact Address Contact E-mail Occupation Representing Current Term of Office from __ to __ Total Years of Service
Board Member Name Contact Address Contact E-mail Occupation Representing Current Term of Office
Contact E-mail Occupation Representing Current Term of Office from __ to __ Total Years of Service
Board Member Name Contact Address Contact E-mail Occupation Representing Current Term of Office
Contact E-mail Occupation Representing Current Term of Office from __ to __ Total Years of Service
Board Member Name Contact Address Contact E-mail Occupation Representing Current Term of Office
Contact E-mail
Board Member Name
Contact E-mail
Occupation Representing Current Term of Office from __ to __ Total Years of Service
Occupation Representing Current Term of Office from __ to __ Total Years of Service
Board Member Name Contact Address Contact E-mail Occupation Representing Current Term of Office from __ to __ Total Years of Service
Board Member Name Contact Address Contact E-mail Occupation Representing Current Term of Office
Contact E-mail Occupation Representing Current Term of Office from __ to __ Total Years of Service
Board Member Name Contact Address Contact E-mail Occupation Representing Current Term of Office
Contact E-mail Occupation Representing Current Term of Office from __ to __ Total Years of Service
Board Member Name Contact Address Contact E-mail Occupation Representing Current Term of Office
Contact E-mail Occupation Representing Current Term of Office from __ to __ Total Years of Service
Board Member Name Contact Address Contact E-mail Occupation Representing Current Term of Office
Contact E-mail Occupation Representing Current Term of Office from __ to __ Total Years of Service
Board Member Name Contact Address Contact E-mail Occupation Representing Current Term of Office
Contact E-mail Occupation Representing Current Term of Office from __ to __ Total Years of Service
Board Member Name Contact Address Contact E-mail Occupation Representing Current Term of Office
Section 3: Staff/Board/Volunteer Descriptors State of Wisconsin Certifications Minority Business Entity (MBE) (51% owned, controlled and actively managed by minorities)
Woman Owned Business Entity (WBE) (51% owned, controlled and actively managed by women)
Disabled Veteran Business (DVB) (51% owned, controlled and actively managed by disabled veterans)
Indicate the number and percentage of the following characteristics for your Agency’s current staff and board. Report total number of volunteers.
Descriptor
Staff Board
Number Percent Number Percent
Total
Gender
Male
Female
Not listed/prefer not to say
Age
Less than 18 Years
18-59 Years
60 and Older
Race
White
Black or African-American
American Indian and Alaskan Native
Asian
Native Hawaiian and Other Pacific Islander
Some Other Race
Two or More Races
Ethnicity
Hispanic or Latino (of any race)
Not Hispanic or Latino
Persons with Disabilities
Volunteers
Section 4: VENDOR INFORMATION
VENDOR NAME:
Vendor Information:
Address below will be used to confirm Local Vendor Preference Address:
City: County:
State: Zip + 4:
Vendor Rep. Name: Title:
E-mail: Telephone:
Dane County Vendor #:
Fair Labor Practice Certification (check only 1) Vendor has not been found by the National Labor Relations Board (“NLRB”) or the Wisconsin
Employment Relations Commission (“WERC”) to have violated any statute or regulation regarding labor standards or relations in the seven years prior to the date this bid submission is signed.
Vendor has been found by the National Labor Relations Board (“NLRB”) or the Wisconsin Employment Relations Commission (“WERC”) to have violated any statute or regulation regarding labor standards or relations in the seven years prior to the date this bid submission is signed.
Local Vendor Purchasing Preference Are you claiming a local purchasing preference under DCO 25.08(7)?
No Yes (complete remainder of this section)
Preference as a Dane County Business: Dane Preference as a business located in a county adjacent to Dane County?
Columbia Green Jefferson Sauk Dodge Iowa Rock
Cooperative Purchasing I agree to furnish the commodities or services of this bid to other municipalities.
I do not agree to furnish the commodities or services of this bid to other municipalities.
Addendums This vendor herby acknowledges receipt/review of the following addendums, if any.
Addendum #1 Addendum #2 Addendum #3 Addendum #4 None
Signature Affidavit In signing this bid, we certify that we have not, either directly or indirectly, entered into any agreement or participated in any collusion or otherwise taken any action in restraint of free competition; that no attempt has been made to induce any other person or firm to submit or not to submit a bid; that this bid has been independently arrived at without collusion with any other bidder, competitor or potential competitor; that this bid has not been knowingly disclosed prior to the opening of bids to any other bidder or competitor; that the above statement is accurate under penalty of perjury.
The undersigned agrees to hold the County harmless for any damages arising out of the release of any material unless they are specifically identified on Attachment B. The undersigned, submitting this bid, hereby agrees with all the terms, conditions, and specifications required by the County in this Request for Bid, and declares that the attached bid and pricing are in conformity therewith.
Signature: Title:
Name: Date:
Section 5: DESIGNATION OF CONFIDENTIAL AND PROPRIETARY
INFORMATION
The attached material submitted in response to this Proposal includes proprietary and confidential information which qualifies as a trade secret, as provided in Sect 19.36(5), Wisconsin State Statutes, or is otherwise material that can be kept confidential under the Wisconsin Open Records law. As such, we ask that certain pages, as indicated below, of this proposal response be treated as confidential material and not be released without our written approval. Attach additional sheets if needed.
Section Page # Topic
Proposer is not designating any information as proprietary and confidential which qualifies as trade secret.
Prices always become public information when proposals are opened, and therefore cannot be designated as confidential.
Other information cannot be kept confidential unless it is a trade secret. Trade secret is defined in Sect. 134(80)(1)(c) Wis. State Statutes, as follows: "Trade secret" means information, including a formula, pattern, compilation, program, device, method technique or process to which all of the following apply:
1. The information derives independent economic value, actual or potential, from not being generally known to, and not being readily ascertainable by proper means by other persons who can obtain economic value from its disclosure or use.
2. The information is the subject of efforts to maintain its secrecy that are reasonable under the circumstances.
In the event the Designation of Confidentiality of this information is challenged, proposer hereby agrees to provide legal counsel or other necessary assistance to defend the Designation of Confidentiality.
Failure to include this form in the proposal response may mean that all information provided as part of the proposal response will be open to examination or copying. The County considers other markings of confidential in the proposal document to be insufficient. The undersigned agrees to hold the County harmless for any damages arising out of the release of any material unless they are specifically identified above.
| Form for RFP_demo.pdf |
| Section 3: Staff/Board/Volunteer Descriptors |
| State of Wisconsin Certifications |
| RFP Attachments.pdf |
| Applicant Summary and Signature Page |
| Section 1. Applicant Information |
| Business Information |
| Fiscal Information |
| Legal Information |
| Section 2: Agency Governing Board |
| Section 3: Staff/Board/Volunteer Descriptors |
| State of Wisconsin Certifications |
| Attachment A: VENDOR INFORMATION |
| Attachment B: DESIGNATION OF CONFIDENTIAL AND PROPRIETARY INFORMATION |
| NumberNot listedprefer not to say: |
| PercentNot listedprefer not to say: |
| NumberNot listedprefer not to say_2: |
| PercentNot listedprefer not to say_2: |
| NumberHispanic or Latino of any race: |
| PercentHispanic or Latino of any race: |
| NumberHispanic or Latino of any race_2: |
| PercentHispanic or Latino of any race_2: |
| NumberNot Hispanic or Latino: |
| PercentNot Hispanic or Latino: |
| NumberNot Hispanic or Latino_2: |
| PercentNot Hispanic or Latino_2: |
| Organization legal name: |
| Mailing address if PO Box include street address: |
| Telephone: |
| Fax number: |
| Name of chief admincontact: |
| Email address of chief admin: |
| Website: |
| Private NonProfit: Off |
| Private ForProfit: Off |
| Other LCC LLP Sole Proprietor: Off |
| Federal EIN: |
| RFP number and title: |
| Contact person: |
| Contact phone number: |
| Contact email address: |
| Title: |
| Printed name: |
| Date: |
| Date business originally established: |
| Number of years under current ownership: |
| How many years have you been doing business under your present firm or trade name: |
| Please list other names under which this business may have operated: |
| If you are working with an accounting firm to handle fiscal operations how long have you worked with this firm: |
| NameRow1: |
| Job TitleRow1: |
| of time spent per week on fiscal dutiesRow1: |
| If less than 100 describe other dutiesRow1: |
| NameRow2: |
| Job TitleRow2: |
| of time spent per week on fiscal dutiesRow2: |
| If less than 100 describe other dutiesRow2: |
| NameRow3: |
| Job TitleRow3: |
| of time spent per week on fiscal dutiesRow3: |
| If less than 100 describe other dutiesRow3: |
| undefined: Off |
| undefined_2: Off |
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| a How many Board meetings has your governing board or Board of Directors scheduled for the current calendar year: |
| b How many meetings were held in the prior calendar year: |
| Board Presidents Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service: |
| Board VicePresidents Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service: |
| Board Secretarys Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service: |
| Board Treasurers Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service: |
| Board Member Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service: |
| Board Member Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service_2: |
| Board Member Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service_3: |
| Board Member Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service_4: |
| Board Member Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service_5: |
| Board Member Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service_6: |
| Board Member Name Contact Address Contact Email: |
| Board Member Name Contact Address Contact Email_2: |
| Occupation Representing Current Term of Office from to Total Years of Service: |
| Occupation Representing Current Term of Office from to Total Years of Service_2: |
| Board Member Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service_7: |
| Board Member Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service_8: |
| Board Member Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service_9: |
| Board Member Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service_10: |
| Board Member Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service_11: |
| Board Member Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service_12: |
| Board Member Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service_13: |
| Board Member Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service_14: |
| Board Member Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service_15: |
| Board Member Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service_16: |
| Board Member Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service_17: |
| Board Member Name Contact Address Contact Email Occupation Representing Current Term of Office from to Total Years of Service_18: |
| undefined_14: Off |
| undefined_15: Off |
| undefined_16: Off |
| NumberTotal: |
| NumberTotal_2: |
| NumberMale: |
| PercentMale: |
| NumberMale_2: |
| PercentMale_2: |
| NumberFemale: |
| PercentFemale: |
| NumberFemale_2: |
| PercentFemale_2: |
| NumberLess than 18 Years: |
| PercentLess than 18 Years: |
| NumberLess than 18 Years_2: |
| PercentLess than 18 Years_2: |
| Number1859 Years: |
| Percent1859 Years: |
| Number1859 Years_2: |
| Percent1859 Years_2: |
| Number60 and Older: |
| Percent60 and Older: |
| Number60 and Older_2: |
| Percent60 and Older_2: |
| NumberWhite: |
| PercentWhite: |
| NumberWhite_2: |
| PercentWhite_2: |
| NumberBlack or AfricanAmerican: |
| PercentBlack or AfricanAmerican: |
| NumberBlack or AfricanAmerican_2: |
| PercentBlack or AfricanAmerican_2: |
| NumberAmerican Indian and Alaskan Native: |
| PercentAmerican Indian and Alaskan Native: |
| NumberAmerican Indian and Alaskan Native_2: |
| PercentAmerican Indian and Alaskan Native_2: |
| NumberAsian: |
| PercentAsian: |
| NumberAsian_2: |
| PercentAsian_2: |
| NumberNative Hawaiian and Other Pacific Islander: |
| PercentNative Hawaiian and Other Pacific Islander: |
| NumberNative Hawaiian and Other Pacific Islander_2: |
| PercentNative Hawaiian and Other Pacific Islander_2: |
| NumberSome Other Race: |
| PercentSome Other Race: |
| NumberSome Other Race_2: |
| PercentSome Other Race_2: |
| NumberTwo or More Races: |
| PercentTwo or More Races: |
| NumberTwo or More Races_2: |
| PercentTwo or More Races_2: |
| NumberPersons with Disabilities: |
| PercentPersons with Disabilities: |
| NumberPersons with Disabilities_2: |
| PercentPersons with Disabilities_2: |
| NumberVolunteers: |
| VENDOR NAME: |
| Address: |
| City: |
| County: |
| State: |
| Zip 4: |
| Vendor Rep Name: |
| Title_2: |
| Email: |
| Telephone_2: |
| Dane County Vendor: |
| Fair Labor Practice Certification check only 1Row1: |
| Fair Labor Practice Certification check only 1Row2: |
| No_2: Off |
| Yes complete remainder of this section: Off |
| undefined_17: Off |
| undefined_18: Off |
| Columbia: Off |
| Green: Off |
| Jefferson: Off |
| undefined_19: Off |
| Dodge: Off |
| Iowa: Off |
| Cooperative PurchasingRow1: |
| Cooperative PurchasingRow2: |
| Addendum 1: Off |
| Addendum 2: Off |
| Addendum 3: Off |
| Addendum 4: Off |
| None: |
| undefined_20: Off |
| Title_3: |
| Name: |
| Date_2: |
| SectionRow1: |
| Page Row1: |
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| Proposer is not designating any information as proprietary and confidential which: Off |
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