Technical_Personnel_List.pdf
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- Community Treatment Services in Brooklyn, NY
- Solicitation number
- RFQ-CTS-019-18
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Technical Personnel List
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NOTE: Only personnel listed on this form will be considered for the solicitation or contract.
TECHNICAL PERSONNEL LIST
Solicitation or Contract Number:
Agency/Company Name:
Address of Performance Site:
Last Name, First Name (as it appears on license)
Title / Position / Authorized Negotiator (point of contact for billing, clinical, etc.)
Professional License Type, DEA License, and Number
License Expiration Date
Employee or Subcontractor
Signature of Authorized Negotiator:
Date:
Page: of
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