ITN_10848_Attachment R.docx

ITN #10848

ATTACHMENT R

CERTIFICATION OF EXPERIENCE

THIS FORM SHALL BE COMPLETED BY THE RESPONDENT AND SIGNED BY A PERSON AUTHORIZED TO MAKE STATEMENTS ON BEHALF OF THE RESPONDENT. RETURN OF THE COMPLETED AND SIGNED FORM IS A MANDATORY REQUIREMENT.

COMPANY NAME:

DATE ESTBLISHED:

PRIMARY BUSINESS:

TOTAL NUMBER OF EMPLOYEES:

NUMBER OF EMPLOYEES ENGAGED IN ACTIVITIES RELEVANT TO THIS ITN: (NOT INCLUDING LOCAL SERVICE PROVIDERS)

NUMBER OF YEARS OF PROVIDER EXPERIENCE IN SERVICES RELEVANT TO THE PROVISION OF MANAGEMENT AND OVERSIGHT OF PROGRAMS SERVING VULNERABLE YOUTH POPULATIONS:

LIST ENTITIES FOR WHOM THE COMPANY HAS PROVIDED SERVICES WITHIN THE LAST FIVE YEARS, THE DATES OF THE PERFORMANCE (RESPONDENT MUST DEMONSTRATE THREE YEARS EXPERIENCE WITHIN THE LAST FIVE YEARS), THE BUSINESS NAME AND CONTRACT MANAGER’S NAME, PHONE NUMBER AND EMAIL ADDRESS:

I, , CERTIFY THAT THE RESPONDENT KNOWN AS HAS AT LEAST YEARS EXPERIENCE WITHIN THE LAST FIVE YEARS RELEVANT TO THE PROVISION OF SERVICES SPECIFIED IN THE ATTACHMENT A (SERVICES SOUGHT) AND ATTACHMENT A-1 (STATEWIDE RESPITE CARE SERVICES).

Signature

Printed Name

Title

Date