RFR 232727 Application form Category 1.doc

The Commonwealth of Massachusetts

Executive Office of Health and Human Services

Department of Public Health Purchase of Service Office 250 Washington Street, Boston, MA 02108-4619

APPLICATION RESPONSE FORM

Category 1 – Previously Developed Course Content

RFR TITLE Specialized Training Services for Small (<$50,000) Projects RFR# 232727

Organization Name: [ ] www: [ ] Address:

City: [ ] State: [ ] Zip: [ ] Contact Person: First Name: [ ] Last Name: [ ]

Title: [ ] Telephone: ( ) -

FAX: ( ) -

E-Mail: [ ] Commonwealth Vendor Customer Code (VCC)* (if available): [ ] Address Code: [ ] *for contract execution

PROFESSIONAL EXPERTISE

List your areas of professional expertise in specialized public health, healthcare or safety training services (maximum of one paragraph).

Enter text here

PROFESSIONAL EXPERIENCE

Describe your experience providing specialized health, healthcare or safety training services. Include staff qualifications, with relevant licenses and certifications.

Enter text here

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Résumé(s) or CV(s) detailing the experience of key specialized health, healthcare or safety training staff attached.

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Copies of relevant staff licenses and certifications attached.

CATEGORY 1: TRAINING WITH PREVIOUSLY DEVELOPED COURSE CONTENT

Describe your course offerings that include:

· course title ● cancellation policy

· brief description ● maximum seating

· all inclusive rate(s)

Enter text here Rates can be offered per seating or for the course as a whole and are all inclusive, with items such as reference materials, books, and any other materials required for the course included. The delivery of services may be provided by trainers with optional coaching and may be stated separately. See section 3.2.1 of the RFR for more information about Instruction with Previously Developed Training Content.

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Information on Course Offerings attached.

Proposed rates attached.

Applicant affirms by signing below, that all individuals that work on a project for DPH will be appropriately licensed and/or Board certified. A copy of license(s) and/or certificate(s) may be required at the time of engagement.

Authorized Signatory:

First Name: [ ] Last Name: [ ] Title: [ ]

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By clicking the check box, the submitter attests that s/he is an agent of the Bidder with authority to sign on the Bidder’s behalf.

REQUIRED APPLICATION DOCUMENTS

The Application Response Form

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Résumé(s) or CV(s) detailing the experience of key specialized health, healthcare or safety training staff attached.

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Copies of relevant staff licenses and certifications attached.

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Information on Course Offerings attached.

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Proposed rates attached.

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Business Reference Form

Additional forms listed on the COMMBUYS Attachment Section for this RFR must be completed and submitted with your response in accordance with the instructions.

APPLICATION INSTRUCTIONS

1. Upload in COMMBUYS the Application Response Form with the required attachments

2. Submit your electronic quote in COMMBUYS. (Vendors must be registered in COMMBUYS to submit quotes)