S000000519 Response Packet~1.docx

BID RESPONSE PACKET

S000000519 Dental & Vision Services

BID SIGNATURE PAGE

PROSPECTIVE CONTRACTOR’S INFORMATION

Company:

Address:

City:

State:

Zip Code:

PROSPECTIVE CONTRACTOR CONTACT INFORMATION

Provide contact information to be used for Solicitation related matters.

Contact Person:

Title:

Phone:

Alternate Phone:

Email:

CONFIRMATION OF REDACTED COPY

☐ YES, a redacted copy of submission documents is enclosed.

☐ NO, a redacted copy of submission documents is not enclosed. I understand a full copy of non-redacted submission documents will be released if requested.

If a redacted copy of the submission documents is not provided with Prospective Contractor’s response packet, and neither box is checked, a copy of the non-redacted documents, except for financial data (other than pricing), will be released in response to any request made under the Arkansas Freedom of Information Act (FOIA). See the Proprietary Information section of the Solicitation.

REQUIRED CERTIFICATIONS

By signing and submitting a response to this Solicitation, Prospective Contractor represents, warrants, and certifies that they are not a Scrutinized Company and they do not currently and shall not for the aggregate term of a resultant contract:

· Boycott Israel.

· Knowingly employ or contract with illegal immigrants.

· Boycott Energy, Fossil Fuel, Firearms, or Ammunition Industries.

· Employ a Scrutinized Company as a contractor.

Prospective Contractor represents, warrants, and certifies that it shall not become a Scrutinized Company during the aggregate term of a contract resulting from this Solicitation. The Prospective Contractor further represents, warrants, and certifies in shall in all other respects comply with the laws, rules, and executive orders of the state that apply to the Contractor’s performance during the aggregate term of a contract resulting from this Solicitation.

An official authorized to bind the Prospective Contractor to a resultant contract shall sign below. The signature below signifies agreement that any exception that conflicts with a Requirement of this Solicitation may cause the Prospective Contractor’s bid to be rejected.

Authorized Signature: Title:

Printed/Typed Name: Date:

SUBMISSION REQUIREMENTS CHECKLIST

The following items must be submitted with the Prospective Contractor’s bid:

· Bid Signature Page

· IFB Requirement Acknowledgements

· Proposed Subcontractors Form

· Copy of Prospective Contractor’s Equal Opportunity Policy

· Official Bid Price Sheet

The following items, which must be submitted prior to a contract award to the Prospective Contractor, may also be included with the Prospective Contractor’s bid:

· EO 98-04: Contract and Grant Disclosure Form

· Current Copy of all required certifications and/or licensure and health certificates as required in this IFB.

PROPOSED SUBCONTRACTORS FORM

Prospective Contractors shall complete the form for all subcontractors the Prospective Contractor proposes to use under a resulting contract (Services Contract (SRV-1) Fillable Form, section 14). If the Prospective Contractor does not intend to use subcontractor(s), Prospective Contractor should indicate so by checking the appropriate box.

Prospective Contractors should not include additional information relating to subcontractors on this form or as an attachment to this form.

Prospective Contractor proposes to use the following subcontractor(s) under a resulting contract:

☐ Prospective Contractor does not propose to use subcontractors under a resulting contract.

07/2025