J-17_ProposalChecklist_03.24.10.doc

RFP-CMS-2010-0016

Attachment J-17 Proposal Checklist

You are requested to complete the following checklist for each proposal jurisdiction. This submission will allow CMS to more readily identify various aspects of your proposal. Please check the appropriate items and provide an explanation, if necessary.

1) Company name, address, point of contact and title, telephone number, email address, and fax number:

2) If a newly formed company, provide name and address of parent companies forming the new entity:

a. __________________ b.__________________

3) List of proposed subcontractors (if applicable) including address, point of contact, telephone number, email address, and fax number:

a. _____________________________________

b. ____________________________________

c. _____________________________________

4) In accordance with RFP Section L.2, indicate the business size of the prime entity/company.

□ Large Business

□ Small Business

5) This proposal is for the following jurisdiction:

J____

6) Indicate whether any work is anticipated to be performed outside the United

States (See RFP L.10.)

□ Yes □ No

7) TIN# ______________

8) DUN Number _______________

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