Disclosure Form.docx
DOCX document 158 KB Posted
- Attached to
- Temporary Staffing Agencies (Direct Award)
- Solicitation number
- 2139500
- Issued by
- New York
About this file
This is a Disclosure Form for a Request for Proposal issued by Roswell Park Comprehensive Cancer Center in New York for temporary staffing services. The RFP seeks proposals from staffing agencies to provide temporary staffing across three categories: Locum Tenens/Allied Health (6 FTEs annually), Non-Clinical/Professional Staffing (40 FTEs annually), and Executive & Faculty Interim Placement and Search Services (3 FTEs annually). Roswell Park intends to use a multi-award model, where one or more agencies may be selected per category, with the option to award one vendor for all categories, multiple vendors across categories, make partial awards, or make no award if responses do not meet needs. Vendors may bid on one or more categories, and submission of a proposal does not guarantee an award.
The Disclosure Form requires bidders to certify their financial stability, legal compliance, and business history by disclosing information regarding bankruptcy or liquidation within the past four years, net losses or negative cash flow, failure to file tax returns, involvement in lawsuits or arbitration related to contract performance, failure to complete projects or contract terminations for nonperformance, pending or threatened litigation, civil or criminal investigations, suspension or debarment from doing business with governmental entities, findings of non-responsibility by governmental entities, and contract terminations or withholdings due to intentional provision of false or incomplete information. Bidders must warrant that all statements are true and accurate as of the signature date, understanding that misstatements will be treated as fraudulent concealment and may impact award consideration. The form identifies 19 business enterprises that were awarded identical or substantially similar procurement contracts within the past five years.
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Other files
| File | Type | Posted |
|---|---|---|
| EEO Policy Statement.docx | DOCX document | |
| Attachment B FINAL.xlsx | XLSX spreadsheet | |
| Non-Collusion Affidavit.docx | DOCX document | |
| Appendix A-1 EEO Requirements (v.12.2025-1)-FINAL Clean.docx | DOCX document | |
| RFP 27-08 Scope of Work FINAL.docx | DOCX document | |
| eo-16 certification.pdf | ||
| EEO Staffing Plan.docx | DOCX document | |
| Attachment A FINAL.xlsx | XLSX spreadsheet | |
| Appendix A Roswell Park Required Clauses (v.12.2025-1)-FINAL Clean.docx | DOCX document |
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Text version
DISCLOSURE FORM
| Request for Proposal Number: |
| Click here to enter text. |
Request for Proposal Title:
| Request for Proposal Date: |
| Click here to enter a date. |
Pursuant to the above referenced Roswell Park Comprehensive Cancer Center (“Roswell Park”), Request for Proposal (the “RFP”), the bidder identified on the last page of this Disclosure Form (the “Bidder”) is disclosing the following to Roswell Park:
1. Has the Bidder now and/or at any time within the past four (4) years been a party to any bankruptcy, liquidation, and/or reorganization of any kind?
|_| Yes |_| No
If yes, explain:
2. Has the Bidder had a net loss and/or negative cash flow within the past four (4) years?
|_| Yes |_| No
If yes, explain:
3. Has the Bidder failed to file any tax returns within the past four (4) years?
|_| Yes |_| No
If yes, explain:
4. Has the Bidder now and/or at any time within the past four (4) years been party to a lawsuit and/or arbitration involving any contract on which the Bidder supplied services, products, and/or materials?
|_| Yes |_| No
If yes, explain:
5. Has the Bidder ever failed to complete a project due to the fault of the Bidder and/or had a contract terminated for failure to perform?
|_| Yes |_| No
If yes, explain:
6. Is the Bidder currently involved in any pending and/or threatened litigation, either by and/or against the Bidder, arising out of any services performed and/or products and/or materials supplied by the Bidder?
|_| Yes |_| No
If yes, explain:
7. Has the Bidder been subject to investigation for a civil and/or criminal violation within the past four (4) years?
|_| Yes |_| No
If yes, explain:
8. Has the Bidder ever been suspended, debarred, and/or disqualified from doing business with any company and/or any Federal, State, and/or local government and/or governmental agency, authority, and/or official, including, but not limited to, Medicare and/or Medicaid Services (a “Governmental Entity” or “Governmental Entities”, as applicable)?
|_| Yes |_| No
If yes, explain:
9. In accordance with State Finance Law §139-k, as amended by Chapter 395 of the Laws of 2006, Chapter 501 of the Laws of 2007, Chapter 169 of the Laws of 2009 and Chapter 4 of the Laws of 2010 (which can be found at https://www.nysenate.gov/legislation/laws/STF/139-K ) has any Governmental Entity made a finding of non-responsibility with regards to the Bidder within past four (4) years?
|_| Yes |_| No
If yes:
Was the basis for the finding of non-responsibility due to a violation of State Finance Law §139-j (which can be found at: https://www.nysenate.gov/legislation/laws/STF/139-J)?
|_| Yes |_| No
Was the basis for the finding of non-responsibility due to the intentional provision of false and/or incomplete information to any Governmental Entity?
|_| Yes |_| No
If yes:
Governmental Entity:
Details Regarding the Finding of Non-Responsibility:
10. Has any Governmental Entity ever terminated and/or withheld a contract with the Bidder due to the intentional provision of false and/or incomplete information?
|_| Yes |_| No
If yes:
Governmental Entity:
Date of Termination and/or Withholding of Contract: / / Basis of Termination and/or Withholding of Contract:
Any defined terms in the RFP shall have the same respective meanings in this Disclosure Form. The Bidder hereby warrants that by signing this Disclosure Form, it is certifying that the above statements are true and accurate as they relate to the Bidder as of the date in which this Disclosure Form is signed by the Bidder as indicated below. The Bidder understands and acknowledges that the above representations are material and important, and will be relied on by Roswell Park in awarding a Resultant Agreement. The Bidder understands and acknowledges that any misstatement in this Disclosure Form is and shall be treated as fraudulent concealment from Roswell Park of the true facts relating to the submission of the Bidder’s Bid Response.
(Bidder)
Signature
Printed Name
Title
Date
| Rev. August 2015 |
| Page 3 of 3 |
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