Inmate-Resident Healthcare Services

Proposal Response Sheet
Shelby County Government -
RFP 26-008-50 - Inmate/Resident Healthcare Services
Shelby County Division of Corrections
Name of firm: ________________________________________________________
Firm's Website: _________________________________
Mailing Address: Remit Address:
________________________________________ _______________________________________
________________________________________ _______________________________________
Phone: ______________________________ Phone: _______________________________
Fax: ________________________________ Fax:_________________________________
Payment Terms:_______________
Authorized Representative: ___________________________ Print: _____________________________________
Signature (Person authorized to negotiate with the County on behalf of the organization/firm.)
Email address: ____________________________________
Authorized Representative: ___________________________ Print:_____________________________________
Signature (Person authorized to negotiate with the County on behalf of the organization/firm.)
Email address: ____________________________________
The signature (s) above indicates that certifies that:
(i) the Proposer's signatory is an agent authorized to submit proposals on behalf of the organization/firm;
(ii) all declarations in the proposal and attachments are true to the best of reasonable knowledge;
(iii) all aspects of the proposal, including cost, have been determined independently, without consultation
with any other prospective Proposer or competitor for the purpose of restricting competition;
(iv) the offer made in the proposal is firm and binding for 90 days after receipt of the proposal by the
County; and
(v) all aspects of this RFP and the proposal submitted are binding for the duration if this proposal is
selected and a contract awarded.
Vendor #___________________ (Required) BRN#:_______________________________ (Required)
If EOC certification was obtained through a Teaming agreement and the BRN starts with a "T", please complete
the next page. If this does not apply, disregard the next page.
______ Check here if you qualify as an LOSB

Page 2
Proposal Response Sheet
Shelby County Government -
RFP 26-008-50 - Inmate/Resident Healthcare Services
Shelby County Division of Corrections
Are you currently in an EOC Teaming Agreement? If so please complete the following:
Please name the firm you agreed to team with in order to be qualified to do business with Shelby
County Government: _____________________________________________________________________
You are aware that part of being approved with a "Teaming Agreement" you agreed to team with the certified LOSB
identified on your agreement on "ALL" County projects?__________
Will this company participate in the completion of services for this proposal?________________
If not, why?_____________________________________________________________________________
______________________________________________________________________________________
If you answered no to the above question, is your Teaming LOSB vendor aware that you are bidding on this project
for the County?__________
Have you included another firm to participate in the completion of the services:__________
If so, who?______________________________________________________________________________
_______________________________________________________________________________________
**Please note that all of the information contained on this page will be used during the evaluation of the responses**
The first page of this document MUST be printed on your company letterhead or stationary.
Definitions for the information listed on the first page
Locally Owned Small Business
As defined in Shelby County Government Ordinances No. 471 and related Amendments.

Response Checklist:
Please make sure that basic information listed below is provided in your RFP before you submit
your response.
Cover Sheet/Proposal Response Sheet (Required)
Comprehensive Response to Minimum Requirements & Required Services
Cost & Fees
Experience of Respondent
References
Additional Information (optional)
(This checklist does not absolve the Respondent of any other required documentation indicated in
the document not list above. Please use the information highlighted above as a reference only)