Attachment C Professional Qualification.pdf
PDF 18 MB Posted
- Attached to
- Medical & Related Services
- Solicitation number
- 99SWC-S107
- Issued by
- Churchill County, Nevada
About this file
Attachment C Professional Qualification.pdf is a document that outlines the professional qualification requirements for a state and local contract opportunity in Nevada for Medical & Related Services.
The document details the requested products and services, including project overviews, item quantities, and the term of the contract with renewal options. Specifically, the contract requires respondents to submit information on their qualifications, experience, and capabilities to provide medical and related services. Responses are due on a specific date, and a bidder's conference may be held prior to the response due date.
The document also addresses pricing terms, set-asides, incumbent information, funding requirements and sources, and other salient details relevant to this contract opportunity.
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Other files
| File | Type | Posted |
|---|---|---|
| ATTACHMENT F Certification Regarding Lobbying~1.docx | DOCX document | |
| Attachment E Insurance~1.docx | DOCX document | |
| List of Services updated 4-25-18.docx | DOCX document | |
| Attachment D Contract~1.docx | DOCX document | |
| Section 3 Background Information Sheet~3.pdf | ||
| Vendor Information Sheet.pdf | ||
| Attachment B Submission Letter.pdf | ||
| RFQ 99SWC-S107 Medical and Related Services.docx | DOCX document | |
| Attachment A 99SWC-S107.docx | DOCX document | |
| Attachment H Sample Work Order~1.doc | DOC document |
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Text version
PROFESSIONAL QUALIFICATION AND CONFIDENTIALITY ATTACHMENT C
APPLICANT'S NAME:
OFFICE ADDRESS: MAILING:
EMAIL: PHONE:
FAX: BIRTHDATE:
GENDER: MALE: FEMALE:
GRADUATE EDUCATION:
MD:
(Name of College) (Year of Degree)
PhD:
(Name of College) (Year of Degree)
PsyD:
(Name of College) (Year of Degree)
EDD:
(Name of College) (Year of Degree)
POST GRADUATE SCHOOL TRAINING (Internship, residency, fellowship, etc):
NAME OF INSTITUTION:
TYPE OF TRAINING:
YEAR OF TRAINING:
LICENSE NUMBER:
EXPIRATION DATE:
NATIONAL BOARD: YES
BOARD CERTIFIED: YES
STATE:
TAX ID#:
NO BOARD ELIGIBILITY: YES NO YEAR:
NO
NATIONAL REGISTER OF HEALTH SERVICES PROVIDERS ON PSYCHOLOGY: YES NO YEAR:
AREAS OF MEDICAL OR PSYCHOLOGICAL EXPERTISE:
SIGNATURE: DATE:
| Submisson Letter Format.pdf |
| 5. By my signature below, I certify that all statements and information provided in Vendor’s Response are true and complete. |
| Sincerely, |
| APPLICANTS NAME: |
| OFFICE ADDRESS 1: |
| OFFICE ADDRESS 2: |
| OFFICE ADDRESS 3: |
| MAILING 1: |
| MAILING 2: |
| MAILING 3: |
| EMAIL: |
| PHONE: |
| FAX: |
| BIRTHDATE: |
| Check Box1: |
| 0: Off |
| 1: Off |
| MD: |
| Year of Degree: |
| PhD: |
| Year of Degree_2: |
| PsyD: |
| Year of Degree_3: |
| EDD: |
| Year of Degree_4: |
| NAME OF INSTITUTION: |
| TYPE OF TRAINING: |
| YEAR OF TRAINING: |
| LICENSE NUMBER: |
| STATE: |
| EXPIRATION DATE: |
| Text12: |
| TAX ID: |
| Check Box2: |
| 0: Off |
| Check Box3: |
| 0: Off |
| Check Box4: Off |
| Check Box5: Off |
| Text8: |
| Check Box6: Off |
| Check Box7: Off |
| Check Box9: Off |
| Check Box10: Off |
| Text11: |
| DATE: |
| Text1: |
File details come from the government source that posted it. Updated .