REQUIRED ATTACHMENTS. Please attach a copy of each of the following documents to your completed Application: ☐ Current state(s) license(s) ☐ Face Sheet of current general and medical liability insurance policy 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 form for each Federal Tax Identification Number 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. ☐ Contract Signature Page ☐ Copy of Medicare Certification Letter ☐ Copy of TJC, AAAHC, or CARF Accreditation (if applicable) Incomplete applications will be returned. Network Facility Application 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 General Information Legal Name of Owner: Trade Name/DBA: Medicare Facility Classification: Medicare Number: License Information State: License Number: Expiration Date: A copy of facility license is required for each state of practice. Accreditation 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: Insurance Information 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: Important Facility Contacts
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 Agreement prior to Business Associate review and execution. For the purposes of this BA Agreement, the following statement applies in regard to Form 1295: Exhibit A is a required component of this BA Agreement. Form 1295 is attached and must be completed prior to approval of this BA Agreement by COUNTY. The Parties involved in this BA Agreement are governmental entities and are not required by the Texas Ethics Commission to complete their Form 1295. Approved on this day of , 2016, by Commissioners Court Order No. . SIGNED AND EXECUTED this day of , 2016. BUSINESS ASSOCIATE Signature _ Printed Name _ Title _ Date COUNTY OF TARRANT STATE of TEXAS B. Xxxx Xxxxxxx County Judge APPROVED AS TO FORM: Criminal District Attorney’s Office*
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. Please attach copies of the following documents. 🞏 NYS-45-MN Quarterly Combined Withholding, Wage Reporting and Unemployment Insurance Form, filed for the quarter ending Dec. 31, . �� For companies that have made sales tax exempt purchases utilizing the sale tax exempt certificate provided to it by the Onondaga County Industrial Development Agency, a copy of NYS ST-340 Annual Statement to NYS Department of Tax and Finance of the value of all sales and use tax exemptions claimed by the Company under the authority granted by the Issuer.
REQUIRED ATTACHMENTS. ❑ List of Board of Directors, officers and titles for applicant organization ❑ IRS Letter of Determination of Status for applicant organization ❑ 2018 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. 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) WHEN COMPLETE, PLEASE RETURN THIS SURVEY ALONG WITH ALL REQUESTED DOCUMENTS TO: J. R. SIMPLOT COMPANY Agribusiness Group, ATTN: Transportation P. O Box 70013 Boise, ID 83707-0113 PLEASE COMMENT ON ANY SPECIAL SERVICES YOUR COMPANY CAN PERFORM, ANY LIMITATIONS, ANY RESTRICTIONS OF YOUR AUTHORITY, AND/OR PREFERRED GEOGRAPHIC TERRITORY (ATTACH SEPARATE SHEET) SIGNATURE OF PERSON COMPLETING FORM Signature: _ Printed/Typed Name: Title: Date: ACH LETTER 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. 1. 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. Owner/Authorized Representative (Signature) Name (Print) Title Firm Name Telephone Date
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. Number of people involved if labor is used as a match for Coastal Dune Restoration Grant Program Funding.
REQUIRED ATTACHMENTS. Detailed written Project Description Copy of registered title (and owner’s consent if applicable for Phase I,II, IV only) Phase I Environmental Site Assessment Report (5 hard copies + one electronic copy) {for Phase II,III,IV only} Phase II Environmental Site Assessment Report (5 hard copies + one electronic copy) {for PHASE II a, b † and c, Phase III and IV only} Remediation Plan {for Phase III and IV only} Business Plan {for Phase III and IV only} Photographs of the present state of the site (5 hard copies and 1 electronic, both high quality) Detailed estimate of Phase (s) cost(s) with each Phase detailed separately Construction schedule and phasing of the project (for Phase III only) Proposed redevelopment plans (for Phase III) or interim solution (Phase IV) Total estimated cost of redevelopment (for Phase III only) or Interim solution (for Phase IV only) Green Building Checklist: “House” or “Large & Commercial Buildings” (p 7 embedded pdf below) (for Phase III only) The Phase III Cost Estimate Template (for Phase III only) Information collected in this application form is not confidential and collected for the purpose of administrating the Xxxxxxxxxx Redevelopment Grant Program. Please note that information related to the Property may be released to various branches within the City of Edmonton and to government agencies as deemed necessary by the City of Edmonton Administration. Green Building Checklist 3rd Draft - F AFFIDAVIT OF EXECUTION TO WIT CANADA PROVINCE OF I, , of the [Name of witness who saw person sign agreement] of , in the [City or Town where witness lives] Province of , MAKE OATH AND SAY:
REQUIRED ATTACHMENTS. (Attachment B) Electronic Funds Transfer (EFT) Agreement – (please complete and sign) Trading Partner Agreement (TPA)– (please complete and sign) Copies of Certificate(s) of Insurance (COI) or Accord-25 or associated form. Copies of required Licenses. Request for Taxpayer Identification Number (W-9) Copy of voided check or bank letter with account and routing number.
