REQUIRED ATTACHMENTS. Please attach a copy of each of the following documents to your completed Application: Insurance Certificate/Face Sheet must have the name or the Facility listed as the insured. The insurance limits must be at the levels in the Contract and must indicate clearly that it is general and medical liability coverage. W-9 forms must be signed and list only the Federal Tax Identification Number listed on the Application which will be used on claim forms submitted to HealthChoice. The completed Network Facility Application should be returned to the Office of Management and Enterprise Services Employees Group Insurance Division in its entirety, accompanied by the applicable attachments. You may mail, fax or email the completed application to: Office of Management and Enterprise Services Employees Group Insurance Division ATTN: Network Management 3545 N.W. 00xx Xx., Xxx. 000 Oklahoma City, OK 73112 Phone: 000-000-0000 or 000-000-0000 Fax: 000-000-0000 XXXX.XxxxxxxXxxxxxxxxx@xxxx.xx.xxx Legal Name of Owner: Trade Name/DBA: Medicare Facility Classification: Medicare Number: State: License Number: Expiration Date: A copy of facility license is required for each state of practice. Is this Facility accredited by The Joint Commission: ☐Yes ☐No Joint Commission Program ID Number: Date of most current accreditation: Expiration Date: Is this Facility accredited by the AAAHC? ☐Yes ☐No Date of most current accreditation: Expiration Date: Is this Facility accredited by CARF? ☐Yes ☐No Date of most current accreditation: Expiration Date: Copy of Insurance Certificate/face sheet is required. Please provide the following information about the Facility’s current general and medical liability insurance coverage. Name of Carrier: Limits of General and Medical Liability Per Occurrence: Expiration Date:
REQUIRED ATTACHMENTS. References (Attachment B) Bidders shall download and complete Attachment B and upload within the MFMP Sourcing application. Bidder shall provide information for a minimum of three mail processing equipment contracts (excluding the Department of Management Services), that individually exceed $100,000.00 (annually), issued between July 1, 2011, and June 30, 2015. Qualification Questions and Required Documents (Attachment C) Bidders shall download and complete Attachment C and upload within the MFMP Sourcing application. Bidders are to meet and respond to the qualifications in order to be considered responsive. The Department may not verify bids from Bidders who answer “No” to any of the Qualification Questions or do not provide all the required documentation. Price Sheet (Attachment D) Bidders shall download and complete Attachment D and upload within the MFMP Sourcing application. The Core Price Sheet lists thirty-six, forty-eight and sixty month lease terms. Bidders must submit pricing for all lease terms for each machine bid. Bidders may submit pricing for multiple machines within the same category. Bidders do not need to submit pricing for machines in all categories. All prices, shall be submitted as whole in U.S. Dollars ($USD; e.g., $99,999.00) and ranges shall not be accepted. Bidders are encouraged but are not required, to bid lease and purchase prices for additional equipment and supplies on Tab 2, “Non-Core Price Sheet” of Attachment D. This tab will not be considered in the award for this ITB. Refer to section 3.1 for further information. Vendor Information Form (Attachment E) The Bidder shall download and complete Attachment E within the MFMP Sourcing application. Ordering Instructions Form (Attachment F) The Bidder shall download and complete Attachment F and upload within the MFMP Souring application. Certification of Drug-Free Workplace (Attachment G) The Bidder shall download and complete Attachment G and upload within the MFMP Sourcing application. Savings/Price Reduction PUR 7064 (Attachment H) The Bidder shall download and complete Attachment H and upload within the MFMP Sourcing application to demonstrate the percent (%) savings in pricing offered compared to the MSRP List or other usual or customary prices that would be paid by the purchaser without the benefit of a contract resulting from this bid.
REQUIRED ATTACHMENTS. This BA Agreement will be considered incomplete without the submission of the completed Form 1295 as referenced in section 9.11. COUNTY shall be responsible to include Form 1295, attached as Exhibit A, to this BA
REQUIRED ATTACHMENTS. Please attach copies of the following documents.
REQUIRED ATTACHMENTS. Please attach a copy of each of the following documents to your completed Application:
REQUIRED ATTACHMENTS. Copy of your interstate operating authority Copy of your liability, cargo, and workmen's compensation insurance certificates (for use until your insurance company provides originals) Copy of your hazardous material certificate (hazmat carriers, brokers and 3PL’s only) Copy of your DOT safety rating notice (if rated) Dear Valued Supplier, J. R. Simplot Company has the ability to pay our suppliers electronically using ACH (Automated Clearing House). As processing checks is costlier than electronic payments, J.R. Simplot Company has selected ACH as the preferred method of payment. ACH provides immediately available funds to our suppliers, payment deposits automatically into your bank account on the due date so you will never have to worry about your check being lost, stolen or delayed.
REQUIRED ATTACHMENTS. List of Board of Directors, officers and titles for applicant organization IRS Letter of Determination of Status for applicant organization 2016 Tax return If prior year funded, a copy of your final program and fiscal reports. Financial Summary Detailed project budget If application is for a capital project, include: o At least three (3) vendor quotes o Certificate of title to property being improved o Letter from property owner (if not applicant) supporting the capital improvement
REQUIRED ATTACHMENTS. color photographs of the improved area after completion of the Project, which includes plantings and the surrounding areas, including required signage receipts for items purchased and details of time and number of people involved, if labor is used as a match for Coastal Dune Restoration Grant Program Funding.
REQUIRED ATTACHMENTS. Highlighted floorplans showing the location of the work and requested alterations.
REQUIRED ATTACHMENTS. A list of the new overall contract amounts for the prime contractor, subcontractors, and vendors. A list of all prior contract amendments, modifications, supplements, and/or change orders leading up to this modification, including those leading up to the amendment which increased the original contract amount by more than 20%. A spreadsheet showing each firm’s participation for the overall contract, including each firm’s participation to date and proposed participation under the modification. A brief description of the work to be performed under this amendment, modification, or change order.
