Business Organization Statement.pdf

PDF 38 KB Posted

Attached to
Statewide Outpatient Services
Solicitation number
23012-3
Issued by
Alamosa County, Colorado

About this file

The document is a Business Organization Statement form issued by the Colorado Judicial Department, located at 1300 Broadway, Suite 1200, Denver, CO 80203. This form is part of a statewide Request for Qualifications (RFQ) for outpatient services for adult and juvenile probationers across multiple judicial districts. The RFQ seeks qualified providers to offer services including substance use treatment, mental health services, DUI programs, domestic violence interventions, cognitive behavioral therapy, specialized treatment, and case management. The solicitation primarily targets the 3rd, 6th, 7th, 9th, 11th, 12th, 13th, 15th, 16th, 21st, 22nd, and 23rd Judicial Districts, though providers are not required to serve the entire state.

The form requires potential contractors to provide detailed business information, including legal business name, contact details, business type, and registration information. Vendors must submit a current W9 form and business registration from the Colorado Secretary of State. The document also includes a mandatory disclosure section regarding any previous debarment from government business. Contractors must attest to meeting all necessary licenses and certifications from DORA, OBH, and/or DVOMB for the specific services they propose to provide. Respondents are not required to offer services in all areas to be eligible for award, providing flexibility for providers with specialized or regional capabilities.

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Business Organization Statement

Colorado Judicial Department 1300 Broadway, Suite 1200

Denver, CO 80203 The below named company is voluntarily submitting this offer and acknowledges that it is consistent with the specifications, terms and conditions, and INCLUDES

ACKNOWLEDGMENT OF ALL MODIFICATIONS POSTED ON THE COLORADO JUDICIAL

DEPARTMENT’S ELECTRONIC BIDDING SYSTEM.

Business (or Individual) Legal Name: (Exactly as it is to appear on the Agreement)

Name and Title: (individual authorized to execute the Agreement on behalf of Respondent)

Agreement Mailing Address: City: State: Zip:

Telephone Number: Email:

Business Type, if applicable, include State where incorporated, (i.e., a Colorado Corporation, a Nevada Limited Partnership, a Sole Proprietor, etc.).

If using a fictitious business name (“DBA”), state name:

Provide a copy of a completed W9 (form must be dated within the current month/year):

Yes ____ No____

Vendors must provide a copy of the business registration/renewal from the Colorado Secretary of State’s website with their proposal.

Debarment: Have you or your firm ever been debarred from doing business with any government entity? Yes No________

If the answer is “YES,” please provide information regarding each debarment by listing on an attached paper the following information; (1) debarring government entity; (2) dates of debarment; and, (3) reason of debarment.

Signature: Title:

Print Name: Date:

Business (or Individual) Legal Name: (Exactly as it is to appear on the Agreement):
Name and Title: (individual authorized to execute the Agreement on behalf of Respondent):
Agreement Mailing Address:
City:
State:
Zip:
Telephone Number:
Email:
Business Type, if applicable, include State where incorporated, (ie, a Colorado:
If using a fictitious business name (“DBA”), state name:
Yes:
No:
government entity? Yes:
No_1:
Print Name:
Title:
Date:

File details come from the government source that posted it. Updated .