Contractor Authorized Signatory Listing (CASL) for Sole Proprietors.pdf
PDF 220 KB Posted
- Solicitation number
- BD-27-1039-EHS01-ASHWA-135088
- Issued by
- Massachusetts
About this file
This document is a Contractor Authorized Signatory Listing (CASL) form for sole proprietors submitted to the Massachusetts Executive Office of Health and Human Services (EOHHS) in response to Request for Responses 27EHSPCAIDCARDPM for Personal Care Attendant Identification Card Services. The CASL form establishes the authorized representatives who may sign documents and execute agreements on behalf of a sole proprietor contractor. This form is a standard procurement requirement that identifies individuals with the legal authority to bind the contractor to contractual obligations and communicate officially with the state agency throughout the procurement process and contract performance period.
The form serves as a compliance and authorization document rather than a pricing or substantive terms document. By submitting this CASL, the sole proprietor contractor designates specific individuals as authorized signatories for all contractual matters related to the RFR response and any resulting contract award. This documentation is essential for ensuring clear lines of authority and accountability between the contractor and EOHHS, and it protects the state by confirming that all signed documents and communications come from individuals with proper authorization to represent the contractor's interests and obligations.
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Other files
| File | Type | Posted |
|---|---|---|
| Standard Contract Form~19.pdf | ||
| Attachment A - PCA ID_Model Contract_Reprocurement.docx | DOCX document | |
| Commonwealth Terms and Conditions~37.pdf | ||
| Supplier Diversity Program (SDP) Plan Form~5.xlsx | XLSX spreadsheet | |
| Prompt Payment Discount Form~12.pdf | ||
| Standard Contract Form Instructions and Certifications~10.pdf | ||
| Business Reference Form~13.docx | DOCX document | |
| Attachment C - Cost Response~1.xlsx | XLSX spreadsheet | |
| Attachment B - Bidder Certifications.doc | DOC document | |
| PCA ID Card RFR_Reprocurement.docx | DOCX document | |
| Evaluation Criteria - PCA ID Card RFR.docx | DOCX document | |
| Attachment D -PCA ID Card Model Contract - Required Card Specifications.docx | DOCX document | |
| Contractor Authorized Signatory Listing (CASL) Form for Contractors.pdf |
Show all 13
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Text version
Commonwealth of Massachusetts
CONTRACTOR AUTHORIZED SIGNATORY LISTING (CASL) FORM
This form is jointly issued and published by the Office of the Comptroller (CTR) and the Operational Services Division (OSD) as the default form for all Commonwealth Departments when another form is not prescribed by regulation or policy.
Notarized Signature for Individual, Sole-Proprietor or Single Member LLC (must match Form W-9 tax classification)
Contractor Legal Name Contractor Vendor/Customer Code (if available, not the Taxpayer Identification Number)
INSTRUCTIONS: Any Contractor, sole-proprietor, or an individual, must provide a notarized signature of the authorized person who can sign contracts and other legally binding documents related to the contract on the Contractor’s behalf.
For privacy purposes DO NOT ATTACH any documentation containing personal information, such as bank account numbers, social security numbers, driver’s licenses, home addresses, social security cards or any other personally identifiable information that you do not want released as part of a public record. The Commonwealth reserves the right to publish the names and titles of authorized signatories of contractors.
Signature (ink on paper) Contractor Signature as it will appear on contract or other documents (Complete only in presence of notary)
Print Signatory’s full legal name Title
Certificate of Acknowledgement of Notary Public Before me, the undersigned notary public, the above named individual proved to me through satisfactory evidence of identification, to be the person whose name is signed above and acknowledged to me that (he)/(she) signed for its stated purpose.
Print Notary Name Notary Signature (ink on paper)
Date My commission expires on
AFFIX NOTARY SEAL/STAMP
A copy of this document must be attached to the “record copy” of a contract filed with the department.
| Commonwealth of Massachusetts |
| CONTRACTOR AUTHORIZED SIGNATORY FORM |
| Contractor Legal Name: |
| Print Signatorys full legal name: |
| Title: |
| Date: |
| My commission expires on: |
| Contractor Vendor/Customer Code: |
| Print Notary Name: |
| AFFIX NOTARY SEAL/STAMP: |
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