ESBD_515780_1778790374785_Form 01-Execution of Application.pdf

This is an Application Execution Form for an open enrollment solicitation issued by the State of Texas (Procurement #3202600156) for Diabetes Self-Management Education Services. The form serves as the official execution document through which applicants commit to providing the services outlined in the open enrollment solicitation. Applicants are required to complete all organizational information fields, including legal entity name, mailing address, contact information, and business identification numbers (Texas Identification Number or Federal Tax ID). The form specifies that applicants must also acknowledge and agree to the Applicant Certifications outlined in section 1.6 of the solicitation document. The signed execution form must be placed behind Form 1 in the enrollment packet as part of the application submission. The applicant must designate their business organization type (such as sole proprietorship, partnership, non-profit corporation, or for-profit corporation) and provide authorization through a designated signatory with the date of execution.

No pricing terms, contract amounts, award dates, contract term information, renewal options, or other salient financial details are included in this execution form document. The form functions solely as a procedural instrument to formalize an applicant's intent to participate in the open enrollment opportunity and their acceptance of the stated certifications and service requirements.