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- S-4 Registration of securities issued in business combination transactions
- 1.1 Exhibit 1.1
- 3.1 Exhibit 3.1
- 3.2 Exhibit 3.2
- 3.3 Exhibit 3.3
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Exhibit 10.21
SECTION 9
ATTACHMENT A
APPLICATION AND QUALIFIED VENDOR AGREEMENT AWARD
APPLICATION and |
| ARIZONA DEPARTMENT OF |
|
| ECONOMIC SECURITY |
QUALIFIED VENDOR AGREEMENT AWARD |
|
|
|
| DIVISION OF |
RFQVA NO. DDD 704011 |
| DEVELOPMENT DISABILITIES |
APPLICATION
TO: THE STATE OF ARIZONA |
|
The undersigned hereby applies and agrees to provide the service(s) in compliance with the RFQVA |
|
|
| |||||
Greg Torres |
| 04-2893910 | |||||
Name |
| Federal Employer Identification Number | |||||
|
|
| |||||
(617) 790-4800 |
| National Mentor Healthcare, Inc. DBA Arizona Mentor | |||||
Phone Number |
| Company Name | |||||
|
|
| |||||
(617) 790-4901 |
| 3724 N. 3rd St. Suite 200 | |||||
Fax Number |
| Mailing Address | |||||
|
|
| |||||
greg.torres@TheMentorNetwork.com |
| Phoenix | AZ | 85012 | |||
Email Address |
| City | State | Zip | |||
|
|
| |||||
If awarded a Qualified Vendor Agreement, |
| 602-200-9494 | |||||
all notices should be sent to: |
| Phone Number | |||||
|
|
| |||||
Kay S. Moore |
| kay.moore@TheMentorNetwork.com | |||||
Name |
| E-Mail Address | |||||
|
|
| |||||
3724 N. 3rd St. Suite 200 |
| /s/ Greg Torres | |||||
Mailing Address |
| Signature & Person Authorized to Sign Application | |||||
|
|
| |||||
Phoenix | AZ | 85012 |
|
| |||
City | State | Zip |
| Greg Torres | |||
|
| Printed Name | |||||
602-200-9494 | 602-200-8588 |
|
| ||||
Phone Number | Fax Number |
| CEO | ||||
|
|
| Title | ||||
kay.moore@TheMentorNetwork.com |
|
| |||||
EMail Address |
|
| |||||
APPROVAL OF APPLICATION AND AGREEMENT AWARD (FOR STATE OF ARIZONA USE ONLY)
Your application is hereby approved. The Qualified Vendor is now bound to provide the service (s) listed in the attached award notice based upon the RFQVA, including all terms, conditions, service specifications, scope of work, amendments, etc., and the Qualified Vendor’s application as accepted by the State.
This agreement shall henceforth be referred to as Qualified Vendor Agreement No. 00455. The begin date and the effective date of this agreement is either the date that this award is signed by the Procurement Officer or July 1, 2003, whichever is later.
| State of Arizona |
| ||
| Awarded this Date: | 7/1/03 |
| |
| /s/ Antonia Valladares |
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| Procurement Officer |
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SECTION 1
NOTICE OF REQUEST FOR QUALIFIED VENDOR APPLICATIONS (RFQVA)
State of Arizona
Department of Economic Security (DES) or (Department)
Division of Developmental Disabilities (DDD) or (Division)
RFQVA Number: DDD 704011
o Time Limited
ý Open and Continuous
Application Due Date:
Pursuant to Arizona Revised Statutes (A.R.S.) § 36-557 and rules adopted thereunder (R6-6-2101 et seq.), which are incorporated herein by reference, Applications for the services listed below will be accepted by the Division at the time and manner specified below. Through this Request for Qualified Vendor Applications (RFQVA) the Arizona Department of Economic Security (DES or Department), Division of Developmental Disabilities (DDD or Division) will execute Qualified Vendor Agreements with providers for the provision of services.
Applications must be submitted electronically using the Qualified Vendor Application and Directory System as well as submitting a printable hard copy with signatures and necessary additional documentation. See Section 3 and Section 9.
Applications will be accepted from current contracted providers beginning April 7, 2003. To assure service continuation effective July 1, 2003 Applications should be submitted by May 1, 2003 at 5 p.m. Arizona time. Applicants new to DDD may submit Applications beginning May 5, 2003. All Applicants shall not expect to be awarded an agreement sooner than 60 days after the submittal of a complete Application. [NOTE: Applications from independent providers as defined in Section 6 will not be processed or result in an agreement until the statewide published rates for independent providers have been adopted in the fall of 2003.]
Submittal Location:
ELECTRONICALLY GENERATED HARD COPY WITH ORIGINAL SIGNATURE
AND NECESSARY DOCUMENTATION
In Person or By Courier to:
DDD Contract Unit, 4th Floor Southwest
Business Operations — Site Code 791A
Division of Developmental Disabilities
Arizona Department of Economic Security
1789 West Jefferson Street
Phoenix, Arizona 85007
(602) 542-6874
I-1
By Mail to:
DDD Contract Unit
Business Operations - Site Code 791A
Division of Developmental Disabilities
Arizona Department of Economic Security
P.O. Box 6123
Phoenix, Arizona 85005
Services:
Home-Based Services: Attendant Care; Habilitation, Community Protection and Treatment Hourly; Habilitation, Support; Housekeeping; and Respite. Day Treatment and Training Services: Day Treatment and Training, Adult; Day Treatment and Training, Children (After-School); and Day Treatment and Training, Children (Summer). Developmental Home Services: Habitation, Vendor Supported Developmental Home (Child and Adult); and Room and Board, Vendor Supported Developmental Home (Child and Adult). Independent Living Services: Habilitation, Individually Designed Living Arrangement. Group Home Services: Habilitation, Community Protection and Treatment Group Home; Habilitation, Group Home; Habilitation, Nursing Supported Group Home; and Room and Board, All Group Homes. Professional Services: Home Health Aide; Nursing; Occupational Therapy; Occupational Therapy Early Intervention; Physical Therapy; Physical Therapy Early Intervention; Speech Therapy; and Speech Therapy Early Intervention. Other Services: Transportation.
First Pre-Application Conference:
Date: March 19, 2003, Arizona Time: 10 a.m. to 2 p.m.
Location: Sheraton Crescent Hotel
2620 West Dunlap Avenue
Phoenix, Arizona
(602) 943-8200
Second Pre-Application Conference:
The second pre-Application conference will be held after the electronic application is released. The purpose of the conference will be to answer specific questions about the electronic application, referred to as the Qualified Vendor Application and Directory System.
Date: March 28, 2003, Arizona Time: Session 1 - 9 a.m. to Noon; Session 2 - 1 p.m. to 4 p.m.
These two sessions will provide the same information. Applicants whose Federal Employer Identification Number (FEIN) or Social Security Number (SSN) ends with an odd number shall attend the morning (9 am to noon) session, and Applicants whose FEIN or SSN ends with an even number shall attend the afternoon (1 p.m. to 4 p.m.) session.
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Location: Auditorium in the basement of the Arizona Land Department
1616 West Adams Street
Phoenix, Arizona
(602) 542-4631
Persons with a disability may request a reasonable accommodation by contacting the RFQVA contact person. (For TDD/TTY call through the Arizona Relay Service at 800 367-8939). Requests should be made as early as possible to allow time to arrange the accommodation.
Agreement Type: Qualified Vendor Agreement with Published Rate
Agreement Term: 12 months beginning no sooner than 7/1/03, with five one-year options for the Division to extend or renew the agreement, with all agreements ending 6/30/09. The agreement can be terminated as specified in Section 6, DES/DDD Terms and Conditions.
RFQVA Contact Person (Phone/email)
Cathie Rodman (602) 542-6896 /CRodman@azdes.gov
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DDD Procurement Specialist | Date |
AN EQUAL EMPLOYMENT OPPORTUNITY AGENCY
I-3