COMPLETE Application and Cover Page.docx

Request For Application (RFA) for Training Services Master Agreement DMH Document Number: 2027-Training-MA-01 October 2026

APPLICATION AND COVER PAGE

COVER PAGE, INSTRUCTIONS, RESPONSE FORM

Application General Instructions:

1. Applicants must complete and submit this Application and Cover Page in the Bid’s COMMBUYS file. Please NOTE IN ADDITION TO THIS APPLICATION AND COVERPAGE APPLICANS MUST SUBMIT THE ADDITONAL INFORMATION SET FORTH IN SUBSECTION 6.3 OF THE RFA.

2. Applicant must respond to each question and request for information set forth in this Form. The answers must demonstrate that the Applicant understands and can meet the requirements of the RFA.

3. Applicants must save and upload their completed Application and Cover Page COMMBUYS using the file naming conventions identified in Subsection 6.4 of the RFA.

4. Applicants are advised to allow adequate time for submission of their Application on COMMBUYS, considering potential online submission impediments like Internet traffic, Internet connection speed, file size, and file volume.

Formatting Instructions for the Application and Cover Page:

This document was prepared using Microsoft Word’s forms feature.

1. Complete the form on your computer using Microsoft Word (MS Word). To do so YOU MUST FIRST SAVE IT TO YOUR COMPUTER. Enter your responses in the text boxes, moving between the text boxes using the tab key on your keyboard.

1. Responses to check boxes are made by clicking once on the check box. To remove the X from a check box, click on the check box again.

1. Text responses are limited to a maximum number of characters, and the limits vary per response. The limit for a response is noted at the end of each response and in the applicable text box. Once the maximum character limit is reached, MS Word will not allow more than this limit. Please note that a space is counted as a character and using the enter key to begin a new line in a response is also counted as a character. It is not recommended that Applicant insert graphics into the responses. Spell check does not work in the text boxes.

1. Where attachments are asked for in this Form, the attachments should be filed in the Attachment file as instructed in Subsection 6.5 of the RFR.

1. Those with visual impairments may use an electronic text reader by unlocking the Application Form.

RFR #______

RESPONSE FORM COVER PAGE

Request For Application For Training Services Master Agreement DMH Document Number: 2027-Training-MA-01 October 2026

Organization Organization or Individual Name:

Address of Principal Place of Business (PO Box not permitted):

City: [ ] State: [ ] Zip: [ ]

State Vendor Customer Code (if Applicant currently has one): [ ]

Website (if applicable): [ ]

FEIN: [ ]

Contact Person First Name: [ ] Last Name: [ ]

Title: [ ]

Telephone: ( ) - FAX: ( ) -

E-Mail: [ ]

Contact Person Address (if different):

City: [ ] State: [ ] Zip: [ ]

Part I Applicant's Organizational Structure

A. Type of organization (check all that apply);

☐ Individual or Sole Proprietorship. Indicate name of individual and Doing Business As name (DBA), if different than individual’s name: [ ] If a DBA, indicate the town with which you filed you DBA certification [ ]

☐ Partnership. Indicate name(s) of Principal Partners: [ ]

☐ Corporation. Indicate type (e.g., ☐ For Profit, ☐ Non-Profit, Indicate state and date of incorporation: [ ] If not A MA Corporation indicate date registered to do Business in MA as a Foreign Corporation [ ] Indicate names of any owner having more than a 2% interest in the Corporation:

☐ Company. Indicate type (e.g., ☐ For Profit, ☐ Non-Profit, ☐ Limited Liability Indicate state and date of formation: [ ].

If not a MA Company indicate date registered to do business In MA as a Foreign Company.

Indicate names of any owner have more than a 2% interest in the Company. [ ]

Certified by the Massachusetts Supplier Diversity Office. If so, Indicate applicable certification(s): ☐ Minority Business Enterprise (MBE), ☐ Minority Non-Profit Organization (MNPO), ☐ Women Business Enterprises (WBE), ☐ Women Non-Profit Organization (WNPO), ☐ Portuguese Business Enterprise (PBE), ☐ Service-Disabled Veteran-Owned Business Enterprise (SDVOBE), ☐ Veteran Business Enterprise (VBE), ☐ Veteran Non-Profit Organization (VNPO), ☐ Disability-Owned Business Enterprise (DOBE), ☐ Lesbian, Gay, Bisexual, and Transgender Business Enterprise (LGBTBE)

☐ Registered Participant of the Massachusetts Small Business Program

B. Number of years in operation

C. Organization Size

1. Leadership Team Name the Authorized Signatory

2. How Many Employees

D. Licensure and Certifications Indicate all relevant licenses, accreditations, certifications, etc. below and provide copies as part of the Attachment file (see RFA 6.3)

1. Organizational licenses (if applicable)

2. Accreditation status (if applicable)

3. Professional licenses/certifications (if applicable)

E. Fiscal Solvency

1. ☐ Check if EOHHS Qualification for Purchase of Service (A bidder may be EOHHS Qualified if they currently have a contract(s) to provide Purchase of Service(s) (POS) to one or more EOHHS state agencies. Provider Qualification Process | Mass.gov)

NOTE: If not EOHHS Qualified you must submit as part of the Attachments file, a copy of one of the following:

☐ a current letter of Credit the Applicant has from a bank or other financial institution, or ☐ a current credit report; or ☐ Certificate of Good Standing and/or Tax Compliance from the Massachusetts Department of Revenue; or ☐ Internal Revenue Service (IRS) Tax Filing Transcript

DMH may request a bidder to furnish supplementary information as is sufficient, in the opinion of DMH, to assure DMH that the Applicant’s business organization and financial resources are adequate to successfully provide the services as set forth in the response. The required copy shall be filed with the attachments.

Liability Insurance |_|The undersigned certifies that the Bidder has the necessary insurance as identified in the RFR.

Describe the nature of the Liability Insurance:

Enter text here; text limit 1,750 characters

2. Debarment The Undersigned affirms the following by Checking YES if the statement is true and No, if not true:

Applicant is not now and was not in the past excluded from participation in the Medicare or Medicaid Program, any state, Commonwealth, or any other federal health care program (collectively “Federal Health Care Program”).

If Applicant is other than an Individual, no owner of the Applicant or employee of the Applicant is now or was in the past excluded from participation in the Medicare or Medicaid Program, any state, Commonwealth, or any other federal health care program (collectively “Federal Health Care Program”).

☐ YES ☐NO

If one or more of the NO boxes are checked, please explain.

Enter text here; text limit 1,750 characters

Part II Training Services Applicant Proposes to Offer to DMH

A. Indicate category of Training Services

☐ Core Service Delivery Principles

☐ Screening, Assessment & Diagnosis

☐ Population-Specific & Specialized Clinical Topics

☐ Evidence-Based & Promising Intervention and Treatment Modalities

☐ Medication & Pharmacology

☐ General Service Delivery Skills

☐ Administrative & Workforce Development

(1) Service Area:

☐Statewide

☐Southeast Area

☐Central MA

☐Metro Boston

☐Northeast Area

☐Western MA

(2) Ages served ☐Children and Adolescents (0-21)

☐Adults (22+)

☐Seniors (55+)

(3) Language capacity

Part III- CERTIFICATION AND SIGNATURE

Application and Cover Page SUBMISSION PAGE

CERTIFICATION OF ASSURANCE OF COMPLIANCE:

ADA/ 504 and NON-DISCRIMINATION BASED ON DISABILITY

All DMH-funded projects must certify that the Applicant Organization will comply with all state and federal requirements regarding equal employment opportunity, nondiscrimination and civil rights for persons with disabilities. The Applicant must complete a Certification of Assurance of Compliance-ADA/504/Non-Discrimination based on Disability. By signing, the Applicant formally notifies DMH that the Applicant is in compliance and shall maintain compliance with all applicable requirements.

· I, certify, that the Applicant is in compliance and shall maintain compliance with all applicable federal and state laws protecting the rights of persons with disabilities, including but not limited to the Americans with Disabilities Act (“ADA”), 42 12131-12134; Section 504 (“504”) of the Rehabilitation Act of 1973, 29U.S.C. §§ U.S.C. § 794; Article CXIV of the Massachusetts Constitution; and Chapter 6, §§ 185-87; Chapter 93, § 103; Chapter 151B; and Chapter 272, §§ 92, 98, and 98A of the Massachusetts General Laws.

· I understand that federal and state laws prohibit discrimination in public accommodations and employment based solely on disability. I recognize that to make goods, services, facilities, privileges, advantages, or accommodations readily accessible to and usable by persons with disabilities, the Applicant, under the ADA, must:

· remove architectural and communication barriers in existing facilities, when readily achievable and, if not readily achievable, must use alternative methods;

· purchase accessible equipment or modify equipment;

· modify policies and practices; and

· furnish appropriate auxiliary aids and services where necessary to ensure effective communication.

I recognize that Section 504 of the Rehabilitation Act requires recipients of federal funds (either directly or through contracting with a governmental entity receiving federal funds) to make their programs, services, and activities, when viewed in their entirety, accessible to qualified and/or eligible people with disabilities. I understand that reasonable accommodation is required in both program services and employment, except where to do so would cause an undue hardship or burden. I also understand that the Massachusetts Constitution Article CXIV provides that no otherwise qualified individual shall, solely by reason of disability, be excluded from the participation in, denied the benefits of, or be subject to discrimination under any program or activity within the Commonwealth.

· I agree the Applicant shall cooperate in any compliance review and to provide reasonable access to the premises of all places of business and employment and to records, files, information, and employees therein for reviewing compliance with Section 504, the ADA, the Massachusetts Constitution, other applicable state and federal laws, and this Contractual Agreement.

· I agree that any violation of the specific provisions and terms of this Assurance and/or Corrective Action Plan and/or Special Contract Conditions required herein or Section 504 or the ADA, shall be deemed a breach of a material provision of the Contract between the Department and the Contractor. Such a breach shall be grounds for cancellation, termination, or suspension, in whole or in part, of this Contract by the Department.

I affirm that I will comply with the requirements of this Request for Application and with the terms of the Response.

Authorized Signatory:

First Name: [ ] Last Name: [ ] Title: [ ] Email: [ ] Phone: [ ]

|_| By clicking the check box, the submitter attests that s/he is an agent of the Applicant with authority to sign on the Applicant’s behalf and is agreeing all affirmations listed above.

APPLICATION INSTRUCTIONS

1. Save, read and review the completed Application Response Form. Check entries in the text boxes to assure that the input limits did not shorten your response. Proofread text; spell-check does not work in the text boxes.

2. Submit the application and all required attachments in COMMBUYS in accordance with Section 6 in the RFA.