RFA 5729 Attachment A application form.pdf

Request for Application (RFA)

OREGONBUYS NUMBER S-10000-00009790/OHA-RFA-5729

Attachment A

Application Form

Applicants must comply with and meet the requirements of the RFA and submit this completed Application Form along with all required information to be considered for a Contract.

Application for Oregon Health Authority (OHA) Oregon Home Care Commission

EMPLOYER RESOURCE CONNECTION TRAINING AND CONSULTATION

Section 1: General Applicant Information (Click in each grey area and begin typing)

Applicant Name/Organization Name:

Mailing Address:

City: State: County: Zip Code:

Office Phone:

Cell Phone:

Contact Name and Title:

Address (if different than above):

City: State: County: Zip Code:

Email:

Section 2: Responsible Applicant Requirements (Double click and check applicable box)

COBID CERTIFICATION

Yes, Applicant has COBID certification in Oregon or Applicant’s home state.

COBID Registration Date/Number Date: Number: State No, Applicant is not currently COBID certified, but is in process of obtaining certification and will notify Agency when complete.

No, Applicant is not eligible for COBID certification.

BUSINESS REGISTRY

Yes, Applicant is currently registered with the Oregon Secretary of State business registry.

No, Applicant is not currently registered with the Oregon Secretary of State business registry but will meet requirement prior to Contract execution.

INSURANCE

Commercial General Liability (CGL) Insurance:

Yes, we currently meet the CGL insurance requirement.

No, we do not currently meet CGL insurance requirements but will meet requirement prior to Contract execution.

Automobile Liability Insurance:

Yes, we currently meet the Auto insurance requirement.

No, we do not currently meet Auto insurance requirements but will meet requirement prior to Contract execution.

Attachment A

Section 3a: Program(s) (Double click and check each box applying for)

Office of Developmental Disabilities Services

Oregon Health Authority’s Health Services Division

Aging and People with Disabilities Section 3b: Area(s) (Double click and check each box applying for. Where multiple county options are listed under an “Area”, choose the county(s) you wish to apply to provide services)

Area 1: Gilliam Hood River Sherman Wasco Wheeler Area 10: Douglas

Area 2: Morrow Umatilla Area 11: Lane

Area 3: Union Wallowa Area 12: Benton Linn

Area 4: Baker Grant Area 13: Lincoln Tillamook

Area 5: Harney Malheur Area 14: Clatsop Columbia

Area 6: Klamath Lake Area 15: Marion Polk Yamhill

Area 7: Crook Deschutes Jefferson Area 16: Washington

Area 8: Jackson Josephine Area 17: Clackamas

Area 9: Coos Curry Area 18: Multnomah

Section 4: Applicant Checklist (Double click and check each box)

APPLICATION FORM

Yes, Applicant has completed all sections of this Application Form in its entirety and signed below.

REFERENCE CHECK FORM

Yes, Applicant has attached THREE complete Reference Check Forms per RFA Section 3.2.4 (Attachment B).

WORK HISTORY

Yes, Applicant has attached a complete response to section 3.2.5 of the RFA.

ORGANIZATIONAL SUMMARY

Yes, Applicant has attached a complete response to section 3.2.6 of the RFA.

CURRENT SERVICES TO SIMILAR CONSUMERS

Yes, Applicant has attached a complete response to section 3.2.7 of the RFA.

EDUCATIONAL OR SKILLS TRAINING MATERIALS EXAMPLES

Yes, Applicant has attached a complete response to section 3.2.8 of the RFA.

PERCENTAGES OF SERVICES

Yes, Applicant has attached a complete response to section 3.2.9 of the RFA.

KEY PERSON(S) AND RESUMES

Yes, Applicant has attached a complete response to section 3.2.10 of the RFA.

Attachment A

Applicant Signature (Click in each grey area and begin typing)

By signing below, Applicant certifies they have read the following and understands the RFA they have applied for.

Applicant certifies qualifications, ability, and availability to provide the training and consultation services described in this RFA and outlined in the Application Packet submitted in response to this RFA.

1. Applicant agrees to be available to provide the proposed services for Program(s) and Area(s) applied for upon execution of a Contract. Applicant shall meet with the Training Manager, learn OHCC curriculum, pick up materials and complete OHCC paperwork as required using own transportation and shall provide services in Program(s) and Area(s) assigned.

2. Applicant understands and will meet the “Responsible Proposer” requirements identified in Oregon Revised Statutes (ORS 279B.110) and applicable Oregon Administrative Rules

3. Applicant does not discriminate in its employment practices with regard to race, creed, age, religious affiliation, sex, disability, sexual orientation or national origin.

4. The statements contained in this Application are true and complete to the best of the Provider’s knowledge.

5. Applicant accepts as a condition of the Contract, the obligation to comply with the applicable state and federal requirements, policies, standards, and regulations. The undersigned recognizes that this is a public document and open to public inspection.

6. The Applicant acknowledges receipt of all addenda issued under this RFA.

7. By signing and submitting this Application to OHCC, the Applicant attests that the Applicant has read and understands this RFA and the sample Contract. The Applicant also agrees that by signing and submitting an Application Packet for this RFA that this RFA, the Contract, and work, if any, assigned work are a binding public contract.

8. Applicant understands that this RFA and the Contract are not, by themselves, a public contract, and do not constitute a promise or commitment by OHCC to assign work. The RFA and the Contract comprise a public contract when work is assigned by OHCC to the Contractor under a resulting Contract.

Applicant Signature (Click in each grey area and begin typing)

Name and Title:

Phone:

Email:

Authorized Signature: