BidderResponseAttachC1 with References.docx

ATTACHMENT C1 - BIDDER RESPONSE TEMPLATE

ADMINISTRATIVE REQUIREMENTS RESPONSE (Pass/Fail)

RFQQ NO. # 27-DCYF-EL-003

Strengthening Families Washington Community-Based Perinatal Mental Health Promotion

Instructions: Bidders must complete this template and attach the PDF to their emailed RFQQ Response. Please thoroughly read all instructions in the RFQQ before completing. All mandatory information must be provided to be responsive. Bidder may provide additional documentation as an additional Attachment; the documentation should be specified in this form. Also, please write your Business Name at the bottom of each page of this Response Template.

ADMINISTRATIVE REQUIREMENTS

Bidder Information:

Business Name:

Address:

Telephone:

Email of Legal Entity or Individual:

· No

Federal Tax Identifier Number:

WA State Uniform Business Identifier (UBI) Number:

· N/A

Unique Entity Identifier (UEI) number:

· No

· N/A

Contract History:

Has the Bidder’s performance on any contract unsatisfactory and resulted in a contract termination in the past five (5) years?

· Yes

· No

If yes, provide a list of those contracts terminated, and include the following:

· Other party’s Name

· Address

· Telephone Number

· Description of the Incident

· Bidder’s Position on the matter

State of Washington Employee(s):

If yes, provide the following information for each individual:

· Name

· Employing Agency

· Job Title while with the Agency

· Separation Date

Bidder’s Exceptions:

If no, please list Bidders exception to the sample contract and general terms and conditions.

Insurance Requirements:

Proprietary or Confidential Information:

If applicable, identify the Sections of the Response which the Bidder considers “Proprietary” or “Confidential” information:

(Optional) OMWBE Certification:

Is Bidder or Bidder’s subcontractor OMWBE Certified?

· Yes

If yes, OMWBE Certification # ______________;

If Subcontractor is OMWBE Certified, Subcontractor’s Name ____________________

(Optional) Veteran Owned Business:

Is Bidder or Bidder’s subcontractor certified Veteran Owned Business?

· Yes

If yes, DVA Certification # ______________;

If Subcontractor is DVA Certified, Subcontractor’s Name ____________________

(Optional) Small Business:

· No

· If yes, please be sure to sign and return Attachment B.1 Small Business Self-Certifications as part of your proposal.

If Subcontractor(s) is a self-certified Washington Small Business, Subcontractor(s) names:

If yes, please be sure return a signed Attachment B.1 Small Business Self-Certifications for each subcontractor as part of your proposal.

Business References:

Provide two (2) names, addresses telephone numbers and e-mail addresses of business references for whom you have provided promotional/marketing materials in the last five (5) years. Please include a brief description of promotional/marketing materials provided.

Reference #1, Name:

Address:

Contact Name:

Contact Telephone:

Contact Email:

Description of Similar Services:

Reference #2, Name:

Address:

Contact Name:

Contact Telephone:

Contact Email:

Description of Similar Services:

Checklist of Mandatory Response Attachments:

· Completed and signed Bidders Certification and Assurances Form (Attachment B)

· Completed Administrative Requirements (Attachment C1; this document)

· Completed Qualifications and Experience & Service Response (Attachment C2)

· Completed Quotation Response (Attachment C3)

Page 4 of 4 RFQQ # 27-DCYF-EL-003