ATTACHMENT E - Customer Reference Template.pdf
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- Attached to
- 163-09012026TB Life Skills Resources
- Solicitation number
- 163-163-09012026TB
- Issued by
- Mecklenburg County, Charlotte City, North Carolina
About this file
This is a Customer Reference Template document issued by the Centers for Medicare & Medicaid Services (CMS) for use in responding to state and local contract solicitations. The template is designed for vendors to submit three customer references as part of their competitive bids. Each reference entry requires documentation of the customer organization name, a designated reference contact person with their address and email, the contract start and end dates, and a detailed explanation of the contract, service agreement, or products and quantities provided. The template is formatted to accommodate three separate customer references with identical information fields repeated for each reference. The document is dated September 2024 and requires vendors to complete the template by filling in the solicitation number and vendor name at the top of the submission.
The related contract opportunity for North Carolina (Solicitation #163-09012026TB Life Skills Resources) seeks vendors to develop and implement comprehensive, evidence-based student wellness, social emotional learning (SEL), and mental health programming. The customer reference template serves as a critical evaluation tool for assessing vendor qualifications and past performance in delivering similar services to educational or organizational clients. Vendors must provide verifiable references from previous clients who can attest to the quality and effectiveness of their wellness and mental health programming services, enabling the state procurement office to evaluate vendor capability and experience relevant to the scope of work.
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Text version
CMS Customer Reference Template Version Date: 09/2024
Page | 1
ATTACHMENT E: CUSTOMER REFERENCE TEMPLATE
Solicitation #: __________________________
Vendor Name: __________________________
Instructions: Vendor shall use this template to submit three (3) customer references with its offer.
Name of Customer Organization:
Customer Reference Name:
Customer Reference Address:
Customer Reference Email:
Start Date:
End Date:
Explanation of contract, service agreement, or type of products and quantity provided to the organization:
Name of Customer Organization:
Customer Reference Name:
Customer Reference Address:
Customer Reference Email:
Start Date:
End Date:
Explanation of contract, service agreement, or type of products and quantity provided to the organization:
Name of Customer Organization:
Customer Reference Name:
Customer Reference Address:
Customer Reference Email:
Start Date:
End Date:
Explanation of contract, service agreement, or type of products and quantity provided to the organization:
ATTACHMENT E: CUSTOMER REFERENCE TEMPLATE
| Solicitation: |
| Vendor Name: |
| Name of Customer Organization: |
| Customer Reference Name: |
| Customer Reference Address: |
| Customer Reference Email: |
| Start Date: |
| End Date: |
| Explanation of contract service agreement or type of products and quantity provided to the organization: |
| Name of Customer Organization_2: |
| Customer Reference Name_2: |
| Customer Reference Address_2: |
| Customer Reference Email_2: |
| Start Date_2: |
| End Date_2: |
| Explanation of contract service agreement or type of products and quantity provided to the organization_2: |
| Name of Customer Organization_3: |
| Customer Reference Name_3: |
| Customer Reference Address_3: |
| Customer Reference Email_3: |
| Start Date_3: |
| End Date_3: |
| Explanation of contract service agreement or type of products and quantity provided to the organization_3: |
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