ESBD_516615_1778878848810_Form 01-Execution of Application.pdf
PDF 91 KB Posted
- Solicitation number
- 3202600157
- Issued by
- Texas
About this file
This is an Execution of Application form for an open enrollment solicitation issued by the State of Texas (Procurement #3202600157) for Independent Living Services for Older Individuals Who Are Blind. The form serves as the application submission document whereby applicants formally agree to provide the services described in the solicitation and certify compliance with all applicable requirements outlined in Section 1.6 of the solicitation document. Applicants must complete all required organizational information fields, including legal entity name, mailing address, contact details, and business classification type, before submitting the signed form as part of their enrollment packet.
The form requires applicants to provide either their Texas Identification Number or Federal Tax I.D. Number as part of the application process. This open enrollment structure allows multiple qualified vendors to be selected to provide services, rather than a single award. No specific pricing terms, contract duration, renewal options, site visit requirements, or response deadlines are detailed within this form itself, as it functions solely as the execution and certification document that must accompany the complete application submission.
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Form 1- EXECUTION OF APPLICATION
Procurement # 3202600157
(Open Enrollment for Independent Living Services for Older Individuals Who Are Blind)
By signing below Applicant agrees to provide the services described in this open enrollment solicitation, and to the Applicant Certifications in sections 1.6 of this solicitation document.
Place your signed Execution of Offer form behind FORM 1 in the Enrollment Packet.
Authorized Signatory
Date Signed
Printed Name
Instructions
1. Provide complete organizational information in the spaces provided below.
2. 2. Enter either your organization’s Texas Identification Number or Federal Tax I.D. Number.
3. 3. Provide your business organization type, e.g. sole proprietorship, partnership, non-profit corporation, for profit corporation etc.
Legal Entity Name
Mailing Address
City, State & Zip Code
Phone No.
E-Mail Address
Texas Identification Number (TIN)
Federal I.D. Tax Number
Business Organization Type
File details come from the government source that posted it. Updated .