Exhibit C_State Corporation Commission Form.pdf
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- Solicitation number
- RFA-128140
- Issued by
- Virginia
About this file
This is a State Corporation Commission Form document supporting the Virginia Rural Health Transformation Program (RHTP) Earn to Learn Initiative, involving Virginia Works as the administering entity in partnership with the Virginia Department of Medical Assistance Services (DMAS). The program seeks to support rural healthcare workforce development through grant funding to eligible applicants. The initiative aims to address healthcare workforce shortages in rural Virginia by providing financial support for training, education, and development programs that prepare workers for careers in rural healthcare settings. The RFA (Request for Applications) contains detailed eligibility criteria, application requirements, funding parameters, and submission deadlines that prospective applicants must follow.
The funding is derived from DMAS as the primary source, with Virginia Works serving as the subrecipient responsible for managing the grant distribution and oversight. Eligible applicants must demonstrate commitment to serving rural healthcare workforce needs and meet specific criteria outlined in the RFA documentation. The program prioritizes support for initiatives that develop healthcare professionals willing to work in underserved rural areas of Virginia, addressing critical workforce gaps in these regions. Award determinations and funding amounts are contingent upon application quality, organizational capacity, and alignment with program objectives as detailed in the formal request for applications.
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Virginia Rural Health Transformation Program Earn to Learn Initiative | RFA #128140
Exhibit C: State Corporation Commission Form
THIS FORM MUST BE RETURNED WITH RESPONSE TO SOLICITATION
Name of Company: _______________________________________________________________
Virginia State Corporation Commission (SCC) registration information. Please complete the following by checking the appropriate box:
❑ is a corporation or other business entity with the following SCC identification number:
-OR-
❑ is not a corporation, limited liability company, limited partnership, registered limited liability partnership, or business trust
-OR-
❑ is an out-of-state business entity that does not regularly and continuously maintain as part of its ordinary and customary business any employees, agents, offices, facilities, or inventories in Virginia (not counting any employees or agents in Virginia who merely solicit orders that require acceptance outside Virginia before they become contracts, and not counting any incidental presence of the bidder in Virginia that is needed in order to assemble, maintain, and repair goods in accordance with the contracts by which such goods were sold and shipped into Virginia from bidder’s out-of-state location)
-OR-
❑ is an out-of-state business entity that is including with this bid an opinion of legal counsel which accurately and completely discloses the undersigned bidder’s current contacts with Virginia and describes why those contacts do not constitute the transaction of business in Virginia within the meaning of § 13.1-757 or other similar provisions in Titles 13.1 or 50 of the Code of Virginia.
**NOTE** Check the following box if you have not completed any of the foregoing options but currently have pending before the SCC an application for authority to transact business in the Commonwealth of Virginia and wish to be considered for a waiver to allow you to submit the SCC identification number after the due date for bids (the Commonwealth reserves the right to determine in its sole discretion whether to allow such waiver): ❑
Authorized Signature Date
Print or Type Name and Title
Legal Name of Company (as listed on W-9)
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