RFP HT941026R2001- Certification Form.docx
DOCX document 23 KB Posted
- Solicitation number
- HT941026R2001
- Issued by
-
Defense Health Agency
About this file
This is a Request for Proposal (RFP) Certification Form for solicitation HT941026R2001, issued by the Defense Health Agency's Healthcare Contracting Division-West. The form serves as a template for offerors to certify their understanding of and compliance with proposal requirements. Offerors must complete the form with their company information, including name, address, CAGE Code, DUNS Number, and SAM Unique Entity Identifier (UEI). The form requires certification of five attachments: Performance Work Statement (PWS), Past Performance Questionnaire, Past Performance Summary Sheet, Pricing Worksheet, and Incumbent Information & Site Specific Information.
The certification form includes two key acknowledgments that must be signed by the contractor. First, the offeror must acknowledge thorough review of the Combined Synopsis/Solicitation and all accompanying documents, including the original solicitation and all amendments, and affirm understanding and acceptance of any changes made during the solicitation process. Second, the offeror must certify willingness to hold prices firm for a minimum of 180 days from the date specified for receipt of offers. This is a template document with no substantive details regarding the IRMAC services requirement itself, which involves centralized Patient Appointing Services, Referral Management Services, and Clear and Legible Report accountability Services for Defense Health Network Indo-Pacific Military Treatment Facilities in Hawaii and the Pacific Northwest.
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Text version
REQUEST FOR PROPOSAL (RFP) CERTIFICATION FORM
RFP number
Offeror’s name
Address
Telephone Number
CAGE Code
DUNS Number
SAM Unique Entity Identifier (UEI)
Point of Contact
Please indicate which attachments are being submitted:
Type of Attachment
☐ Attachment 1– Performance Work Statement (PWS)
☐ Attachment 2- Past Performance Questionnaire
☐ Attachment 3– Past Performance Summary Sheet
☐ Attachment 4–Pricing Worksheet
☐ Attachment 5–Incumbent Information & Site Specific Information
Proposal Certification Form
I, [the contractor], hereby acknowledge that I have thoroughly reviewed the Combined Synopsis/Solicitation and all accompanying documents. These materials are based on the original solicitation and all amendments.
By signing this acknowledgment, I affirm that I understand and accept any changes made during the solicitation process. This includes amendments, clarifications, and updates related to the RFP.
Should any discrepancies arise, I commit to addressing them promptly and in accordance with the terms outlined in the proposal.
| ___________________________________ | |
| Name | Date |
| Contractor Organization |
I, [the contractor], hereby acknowledge that we are willing to hold prices firm for at least 180 days from the date specified for receipt of offers.
| _______________________________ | ||
| Name | Date | |
| Contractor Organization |
File details come from the government source that posted it. Updated .