Provider's Qualifications and Service Application Form.docx

Request for Application For Group Transportation Master Agreement DMH Document Number: DMH-2025-3030-01 July 2024 Provider’s Qualifications and Service Application Form

APPLICATION FORM, INSTRUCTIONS, AND CHECKLIST

Application General Instructions:

1. Applicants must complete and submit this Provider’s Qualification and Service Application Form (Application Form) and the Cost Response Workbook included in the Bid’s COMMBUYS file.

2. Applicant must respond to each question and request for information set forth in this Provider’s Qualifications and Service Application Form. Applications must demonstrate that the Applicant understands and can meet the requirements of the RFA.

3. Applicants must save and upload their completed Provider’s Qualifications and Service Application Form and required attachments into COMMBUYS using the file naming conventions identified in Subsection 7.3.2 of the RFA.

4. Applicants are advised to allow adequate time for submission of their Application on COMMBUYS, considering potential online submission impediments like Internet traffic, Internet connection speed, file size, and file volume.

Formatting Instructions for the Provider’s Qualifications and Service Application Form:

This document was prepared using Microsoft Word’s forms feature.

1. Complete the form on your computer using Microsoft Word (MS Word). To do so YOU MUST FIRST SAVE IT TO YOUR COMPUTER. Enter your responses in the text boxes, moving between the text boxes using the tab key on your keyboard.

1. Responses to check boxes are made by clicking once on the check box. To remove the X from a check box, click on the check box again.

1. Text responses are limited to a maximum number of characters and the limits vary per response. The limit for a response is noted at the end of each response and in the applicable text box. Once the maximum character limit is reached, MS Word will not allow more than this limit. Please note that a space is counted as a character, and using the enter key to begin a new line in a response is also counted as a character. It is not recommended that Applicant insert graphics into the responses. Spell-check does not work in the text boxes.

1. Where attachments are asked for in this Form, the attachments should be filed in the Attachment file as instructed in Subsection 7.3.2 of the RFA.

1. Those with visual impairments may use an electronic text reader by unlocking the Application Form.

RFR #______

APPLICATION COVER PAGE

Request for Application For Group Transportation Master Agreement DMH Document Number: DMH-2025-3030-01 Provider’s Qualifications and Service Application Form

Make this the first page of your Service Application

Organization Organization or Individual Name:

Address of Principal Place of Business (PO Box not permitted):

City: [ ] State: [ ] Zip: [ ]

State Vendor Customer Code (if Applicant currently has one): [ ]

Website (if applicable): [ ]

Contact Person First Name: [ ] Last Name: [ ]

Title: [ ]

Telephone: ( ) - FAX: ( ) -

E-Mail: [ ]

Contact Person Address (if different):

City: [ ] State: [ ] Zip: [ ]

Request for Application For Group Transportation Master Agreement DMH Document Number: DMH-2025-3030-01 A note about the text boxes: Text input is limited to a maximum number of characters. MS Word will not allow more than this limit. Spaces, commas, line breaks, etc. are counted as characters. The spell-check feature does not work in the text boxes.

Part I Application Overview

a. Preferred Service Area

DMH Area (check all that apply) check all that apply

b. Available Transportation

c. Rebid

If you have filed a previous Application to this RFA, indicate how this response is different from the one previously filed, Text input limit 1,750 characters, approximately 250 words).

Enter text here; text limit 1,750 characters

Part II Applicant’s Background / Experience

a. Type of organization (check all that apply);

|_| Sole Proprietorship. Indicate name of individual and Doing Business As name(DBA), if different than individual’s name:

[ ] If a DBA indicate the town with which you filed you DBA certification [ ]

|_| Partnership. Indicate name(s) of Principal Partners: [ ]

|_| Corporation. Indicate type (e.g., |_|For Profit, |_|Non-Profit, |_|Limited Liability Indicate state and date of incorporation: [ ]

|_| Certified by the Massachusetts Supplier Diversity Office. If so, Indicate applicable certification(s): |_| Minority Business Enterprise (MBE), |_| Minority Non-Profit Organization (MNPO), |_| Women Business Enterprises (WBE), |_| Women Non-Profit Organization (WNPO), |_| Portuguese Business Enterprise (PBE), |_| Service-Disabled Veteran-Owned Business Enterprise (SDVOBE), |_| Veteran Business Enterprise (VBE), |_| Veteran Non-Profit Organization (VNPO), |_| Disability-Owned Business Enterprise (DOBE), |_| Lesbian, Gay, Bisexual, and Transgender Business Enterprise (LGBTBE)

|_| Registered Participant of the Massachusetts Small Business Program

b. Overview of Applicant’s Business: Provide a description of the Applicant’s business (e.g., history, years in business, principal services offered, number of current customers; primary customers, service population, number of full and part time employees, hours of operation; licenses and certifications; and awards and recognition in the last 3 years. Text input limit: 7,000 characters, approximately 1,000 words)

Enter text here; text limit 7,000 characters

c. General Experience. Describe the Applicant’s experience and expertise related to providing safe and dependable charter transportation services to large groups of adults (48 or more individuals at one time) to designated locations. Attach a client list and a list of all Massachusetts state agencies to which you have provided services. (Text input limit: 7,000 characters, approximately 1,000 words).

|_| List of clients and Massachusetts state agencies to which you have provided services uploaded to COMMBUYS.

Enter text here; text limit 7,000 characters

d. References. An Applicant must attach three (3) professional references that can provide examples of similar or comparable services the Applicant has provided to them within the last five years. DMH or its agents may contact any individual/company named as references and any other individual/company known by DMH to have done business with the Applicant. Applicants must use the Business Reference Form included in this Bid’s COMMBUYS file for this purpose.

|_| 3 Business Reference Forms uploaded to COMMBUYS.

e. Principal Personnel for the Contract awarded under the RFA. Indicate who will be the principal personnel involved in the management and operations of the Contract, if you are awarded one; indicate the roles they will play and provide a brief overview of their experience, credentials and current positions held within the Applicant’s organization. (Text input limit: 3,500 characters, approximately 500 words)

Enter text here; text limit 3,500 characters

f. Department of Public Utilities Certificate. Attach a copy of the applicable Operating Authority Certificate(s) granted by the Department of Public Utilities. Indicate if you ever held a Certificate from this Department that was suspended or revoked? If so indicate the circumstances. Text input limit 1,750 characters, approximately 250 words).

|_| Department of Public Utilities Certificates (s) uploaded to COMMBUYS.

g. Fiscal Solvency.

1. Check if the Applicant is currently Qualified by the Massachusetts Executive Office of Health and Human Services (EOHHS) to contract to provide Human Services to EOHHS agencies |_|.

If not EOHHS Qualified, provide a copy of one of the following as an attachment: (1) a current balance sheet (2) Letter of Credit the Applicant has from a bank or other financial institution, (3) a current credit report; or (4) the most recently completed and filed Tax return. DMH may request an Applicant to furnish supplementary information as is sufficient, in the opinion of DMH, to assure DMH that the Applicant’s business organization and financial resources are adequate to successfully provide the services as set forth in the response.

|_| Selected Financial Information uploaded to COMMBUYS.

2. Affirm the following by Checking YES if the statement is true and No if not true.:

If one or more of the NO boxes are checked, please explain. Text input limit 1,750 characters, approximately 250 words).

h. Subcontractors: If the Applicant intends to use a subcontractor(s) in providing transportation to DMH, Identify the subcontractors (name, address, and the roles that they will play). All Subcontracts are subject to the approval of DMH. (Text input limit 1,000 characters, approximately 140 words).

Enter text here; text limit 1,000 characters

i. Environmental Preferable Products Please indicate which or the following business practices the Applicant has adopted to foster a sustainable approach to conducting their operations. Applicants need to meet at a minimum one of the business practices below, preference will be given to those that meet more than one of the business practices. DMH reserves the right to ask for additional information or documentation.

|_| Uses at least 50% remanufactured toner cartridges in printers.

|_| Uses Green Cleaning products (certified by UL Ecologo, GreenSeal or SaferChoice) in all cleaning or janitorial services.

|_| Purchase appliances and equipment (printers, copiers, microwaves, etc.), that are Energy Star or EPEAT certified models.

|_| Incorporates green building design elements into all construction and renovation projects.

|_| Owns or leases buildings certified to LEED or another green building standard.

|_| Purchases or creates renewable electricity onsite (through solar or wind systems, for example).

|_|Has received a third party energy audit (usually through the utility) and implemented recommendations.

|_| Has received a third party waste audit and implemented recommendations.

|_| Other sustainable initiatives, indicate initiatives: (e.g., waste reduction programs, green building management programs, other energy efficiency programs, etc.)

Part III Service Requirements

a. Vehicles:

1. Vehicles. Complete this chart for each vehicle that could be used if awarded a Master Service Contract . If more space is needed, you may add as an attachment a chart containing the same information for the additional vehicles.

2. Maintenance. Describe the Applicant’s vehicle maintenance policy. Indicate if the Applicant follows a regular maintenance schedule and maintain vehicle maintenance logs. Describe if the maintenance program is internal or external. If you maintain vehicle maintenance logs, attach a sample from one of the maintenance logs for one of your vehicles

Enter text here; text limit 6,000 characters

|_| Sample Maintenance Log is uploaded to COMMBUYS.

b. Drivers

1. Applicant’s Safety, Training, and Drug Testing Program. Describe Applicant’s screening process for hiring drivers. Indicate if drivers are employees or independent contractors. (Text input limit: 3,500 characters, approximately 500 words)

2. Evaluating Drivers. Describe the Applicant’s process for supervising and evaluating drivers once hired. (Text input limit: 3,500 characters, approximately 500 words)

3. Safety, Training Drug Testing. Describe your company’s safety, training, and drug testing program. (Text input limit: 3,500 characters, approximately 500 words)

4. Confidentiality. Indicate how you will address the confidentiality requirements set forth in the RFA. (Text input limit: 3,500 characters, approximately 500 words)

c. Customer Service. Describe the Applicant’s quality control program and how you handle customer Services. (Text input limit: 3,500 characters, approximately 500 words)

d. Safety Record. Describe the Applicant’s safety record for the last five years. This should include a detailed description of the measures and data collected to determine the record for each year. It should also indicate if any third party (e.g., Federal Department of Transportation The Transportation Safety Exchange, etc.) in the past five years have rated the Bidding organization on safety and if so what ratings the Bidding organization received. Attach any documentation you may have that supports your response.(Text input limit: 3,500 characters, approximately 500 words)

|_| Supporting documentation uploaded to COMMBUYS.

Part IV - Verification/Signature

I hereby certify that the statements contained in this application herein made are full, just, and true to the best of my knowledge and belief. This statement is made under the penalties of perjury.

Authorized Signatory:

Title: [ ]

By clicking the check box, the submitter attests that s/he is an agent of Applicant with authority to sign on the Applicant’s behalf and agree to the certification stated above.

I affirm, on behalf of the Applicant, that if the Applicant is awarded a Contract the Applicant will comply with the requirements of this Request for Response and with the terms of this Response.

Authorized Signatory:

Title: [ ]

By clicking the check box, the submitter attests that s/he is an agent of Applicant with authority to sign on the Applicant’s behalf and is agreeing to affirmations listed above.

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