Schedule B to the Request for Proposals – Equipment and Supplies Template – Final Version – April, 2011

Schedule B Proposal Submission Form

Schedule B to the Request for Proposals – Equipment and Supplies Template – Final Version – April, 2011

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PROPOSAL SUBMISSION FORM SCHEDULE B TO THE RFP TO:

[CCAC Name, Address, RFP Coordinator]

RE:

[Complete name of RFP]

1.

Respondent Information [Note: For items (a), (b) and (c) Joint Venture Respondents, provide information for the joint venture Participant in Charge and for Applicant Teams, information for the Prime Contractor.]

(a)

Respondent’s registered legal business name and any other name under which it carries on business:

(b)

Respondent’s address, telephone and facsimile numbers:

(c)

Name, address, telephone, e-mail and facsimile numbers of the contact person(s) for the Respondent:

(d)

Name of the person/Joint Venture Participant who is the joint venture Participant in Charge: [Note: Item (d) is only applicable to Joint Venture Respondents.]

[Note: For items (e) and (f), provide the information for the Respondent, the prime contractor and the Joint Venture Respondent, as applicable.] (e)

Whether the Respondent is an individual, a sole proprietorship, a corporation, a partnership, a joint venture, an incorporated joint venture or a joint venture that is a partnership or other legally recognized entity:

Schedule B to the Request for Proposals – Equipment and Supplies Template – Final Version – April, 2011

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(f)

Name(s) of the proprietor (where the Respondent is a sole proprietor), names of each of the directors and officers (where the Respondent is a corporation) names of each of the partners (where the Respondent is a partnership) and applicable combinations of these when the Respondent is a joint venture, whichever applies:

(g)

Respondent’s location for the purposes of the site visit (if different from address in 1(b)):

2.

Applicant Teams

[Note: If the Respondent is submitting the Proposal on behalf of a Prequalified Applicant Team, complete the information in 2(a). If the Respondent is submitting the Proposal on behalf of a New Applicant Team, complete the information in 2(b). If the Respondent is a single entity or Joint Venture Respondent, no information is required for Section 2.] (a)

Prequalified Applicant Team

If the Respondent is submitting the Proposal on behalf of a Prequalified Applicant Team, provide the following information: (i) Name of the Prime Contractor:___________________________ (ii) Prequalification Level of the Prequalified Applicant Team:__________________ (iii) List of Prequalified Applicant Team Members that form the Prequalified Applicant Team _____________________________________________________________________________ _____________________________________________________________________________ We confirm that the Team Members listed in this Section 2(a) are the same as the Prequalified Applicant Team Members prequalified as part of the Provincial Prequalification Process . (b)

New Applicant Team

If the Respondent is submitting the Proposal on behalf of a New Applicant Team, provide the following information: Full Legal Name of Applicant Team Member

Role of Team Member in New Applicant Team

1.

[Note: Insert either Prime Contractor or Subcontractor]

Prequalification Level of Applicant Team Member

Schedule B to the Request for Proposals – Equipment and Supplies Template – Final Version – April, 2011

3.

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Joint Ventures

[Note: If the Respondent is a Prequalified Joint Venture Respondent, complete the information in 3(a). If the Respondent is a New Joint Venture Respondent, complete the information in 3(b). If the Respondent is a single entity or an Applicant Team, no information is required for Section 3.] (a)

Prequalified Joint Venture Respondents

If the Respondent is submitting the Proposal on behalf of a Prequalified Joint Venture Respondent, provide the following information: (i) Prequalification Level of the Prequalified Joint Venture Respondent:__________________ (ii) Identification of each individual Joint Venture Participant: Name of entity that is a Joint Venture Participant (List whether Sole Proprietor, Partnership or Corporation)

Role in Joint Venture

Representative Signing Proposal and Position of Representative (on behalf of the Joint Venture Participant)

1.

We confirm that the entities listed in this Section 3(a) are the same as the entities consisting of the Prequalified Joint Venture Respondent prequalified as part of the Provincial Prequalification Process . (b)

New Joint Venture Respondent

If the Respondent is submitting the Proposal on behalf of a New Joint Venture Respondent, provide the following information: Name of Person/Firm that is a joint venture participant (List whether Sole Proprietor, Partnership or Corporation)

Role in Joint Venture

Representative Signing Proposal and Position of Representative

Prequalification Level of Each Joint Venture Participant

1.

4.

Offer

With respect to the above noted RFP, we confirm as follows: (i)

capitalized terms used in this Proposal Submission Form have the meanings as set out in the RFP Documents;

(ii)

we have examined the RFP Documents, including those that were not directly distributed by the CCAC but were available on the Ontario Association of Community Care Access Centres’ website, and confirm that we have received all pages of all documents constituting the RFP Documents;

(iii)

in our completion of this Proposal Submission Form we have not amended the Proposal Submission Form in any way except to provide the information requested;

Schedule B to the Request for Proposals – Equipment and Supplies Template – Final Version – April, 2011

5.

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(iv)

we have made any necessary inquiries with respect to Addenda issued by the CCAC (if any) and have ensured that we have received and examined all Addenda to the RFP Documents that were issued;

(v)

by the submission of our Proposal we submit a binding offer to carry out all Services and meet all obligations described in the RFP Documents in accordance with the terms and conditions of the RFP Documents;

(vi)

our Proposal is based on the terms and conditions of the RFP Documents and we understand and agree to be bound to the terms and conditions of the RFP in respect of the RFP Process and the Draft Agreement if we are awarded an Agreement;

(vii)

the prices contained in our Price Submission Section are based on the terms and conditions of the RFP Documents;

(viii)

we agree to hold our Proposal open for acceptance until the expiration of the Proposal Validity Period set out in the RFP Documents; and

(ix)

we acknowledge and agree that any geographic designations referred to in RFP Section 10.3 are subject to change in accordance with the Draft Agreement; and

(x)

there has been no material adverse change to the Respondent, Prequalified Applicant Team or Prequalified Joint Venture, as applicable since the date of the Respondent’s, Prequalified Joint Venture’s Prequalification pursuant to the Ontario Association of Community Care Access Centre’s Prequalification Process.

Conflict of Interest and Confidential Information (i)

We confirm that we do not have any actual, potential or perceived Conflict of Interest or any other type of unfair advantage in submitting our Proposal or performing or observing the contractual obligations set out in the Draft Agreement, except to the extent that such Conflict of Interest, perceived Conflict of Interest or potential Conflict of Interest is disclosed in Section 5(iv) of this Proposal Submission Form.

(ii)

We confirm that we have not had access to CCAC confidential information, other than the RFP Documents themselves, with respect to this RFP Process, except as disclosed in Section 5(iv) of this Proposal Submission Form.

(iii)

We confirm that the names, positions, addresses and telephone numbers of all individuals who participated in the preparation of this Proposal and the identification of any of those individuals who are former employees, former Executive Directors or former members of the Board of Directors of the CCAC issuing this RFP are set out in Section 5(iv) of this Proposal Submission Form.

(iv)

Details of any Conflict of Interest/Confidential Information The following are actual, potential or perceived of Conflicts of Interest: 1. 2. 3. [Respondent to add more rows if necessary.]

Schedule B to the Request for Proposals – Equipment and Supplies Template – Final Version – April, 2011

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OR We confirm that we do not have any actual, potential or perceived Conflict of Interest. [Respondent to strike out and initial statements that are NOT APPLICABLE. DO NOT ELECTRONICALLY DELETE THE STATEMENT.] The following are the names, positions, addresses and telephone numbers of all individuals who participated in the preparation of this Proposal, including and identifying any of those individuals who are former employees, Executive Directors or members of the Board of Directors of the CCAC issuing this RFP: 1. 2. 3. [Respondent to add more rows if necessary.] In addition to the RFP Documents, we have access to the following confidential information relating to the RFP Process. 1. 2. 3. [Respondent to add more rows if necessary.]

OR We confirm that we do not have access to any confidential information relating to the RFP Process other than the RFP Documents. [Respondent to strike out and initial statement that is NOT APPLICABLE. DO NOT ELECTRONICALLY DELETE THE STATEMENT. ]

Schedule B to the Request for Proposals – Equipment and Supplies Template – Final Version – April, 2011

6.

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Proposal Streaming

We are applying for an award in the following Proposal Streams: 1. 2. 3. [Respondent to add more rows if necessary.] [Respondent to list Proposal Streams for which it is applying here. If Proposal Streaming is not applicable to this RFP, strike out and initial statement.] Our preferred Proposal Stream (if any) is: 1. 2.

7.

Geographic Designation

[Note: To be completed ONLY if the CCAC has completed the “Geographic Designation” section of the RFP Data Sheet. The only geographic area preferences that can be identified are those set out in the RFP Data Sheet by the CCAC, if any.] Our preferred geographic area (if any) is: 1. 2.

Schedule B to the Request for Proposals – Equipment and Supplies Template – Final Version – April, 2011

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Signed by person or persons authorised to bind the Respondent or joint venture participant, as applicable in accordance with RFP Section 5.1.

Signed by person or persons authorised to bind the Respondent or joint venture participant, as applicable in accordance with RFP Section 5.1.1

Print Name and Title of Person Signing

Print Name and Title of Person Signing

Signed by person or persons authorised to bind the Respondent or joint venture participant, as applicable in accordance with RFP Section 5.1.

Signed by person or persons authorised to bind the Respondent or joint venture participant, as applicable in accordance with RFP Section 5.1.1

Print Name and Title of Person Signing

Print Name and Title of Person Signing

[Note to Respondents/Joint Venture Respondents – Review signature requirements in the RFP. ALL JOINT VENTURE PARTICIPANTS must sign this document.] [Note to Applicant Teams – only the Prime Contractor signs this document.] 12249442.8