APPLICANT PROPOSAL For Non-Emergency Medical Transportation (NEMT) Coordination Services
|
|
- Martha Dixon
- 8 years ago
- Views:
Transcription
1 1 APPLICANT PROPOSAL For Non-Emergency Medical Transportation (NEMT) Coordination Services INSTRUCTIONS: If you want to be considered to provide services in response to the Request for Proposals for NEMT Coordination by Stearns County Department of Human Services, please complete this Proposal in the format provided below. Please write directly on this document and use additional paper when required to provide complete information, but do not send additional documentation not requested as part of this proposal. Return the original plus five (5) copies of the proposal. I. GENERAL INFORMATION Business Name: Business Address: Home Office Address (if different from business address): Business Telephone: Business Fax: Contact Person and Title: Name and Title of Person Authorized to sign a Contract for Your Business: II. ORGANIZATIONAL STRUCTURE A. Please identify your organizational status: Sole Proprietorship Partnership For Profit Corporation Non-Profit Corporation LLC Other (specify) B. If you are a partnership identify all partners:
2 2 C. If you are incorporated or organized as an LLC provide your articles of incorporation or organization, bylaws, names of current directors, organizers, members and officers. D. Provide a complete organizational chart for your organization. E. Provide a description of your organization: its history, capacity, number of employees, vision, goals and philosophy of service. III. INSURANCE & OTHER REQUIREMENTS Provide proof of insurance and other requirements listed in Lead County Contact Prerequisites, Attachment A. IV. PROPOSED SERVICE(S): A. Executive Summary: Provide a brief (less than 3 pages) summary of the services you propose to provide for Stearns County clients. B. Proposed Statement of Work: Provide a detailed description of how you would provide NEMT coordination services in Stearns County. At a minimum include how you would: Market and inform stakeholders and clients of an NEMT coordination system in Stearns County Establish and maintain a call center including service during business hours and afterhours service. Include procedures used to report numbers, trends and disposition of calls to County on a regular basis. Handle incoming inquiries for NEMT including screening, determination of eligibility, handling of emergency requests, verification of participation in a fee for service plan, etc. Also include procedures to provide information to callers regarding services, grievances, rights and responsibilities. Determine the most appropriate and cost-effective type of transportation service given the client s level of mobility and functional independence. How would you determine if the client has any special needs that would influence the type of transportation provided? Arrange and schedule NEMT rides, including rides that are outside of Stearns County, outside of state, require air transport or the use of a stretcher. Also include procedures for providing lodging and meals when required. Establish and maintain an adequate transportation provider network. Include a model service agreement/contract between your organization and a transportation provider. Include any volunteer driver networks and public transportation. Do you provide
3 3 assistance to your provider network to remain in compliance with requirements? How do you monitor compliance and what are your procedures for non-compliance? Schedule rides for clients in a cost effective manner, while adhering to a reasonable pick-up and delivery schedule for clients. Obtain reimbursement for services from the Minnesota Department of Human Services and assume responsibility for unclaimable transportation costs Monitor fraud, waste and abuse of transportation services and employ corrective action when needed. Reimburse clients for eligible health care access costs incurred such as mileage and other travel expense. Handle unexpected circumstances such as last minute cancellations, last minute requests for transportation, no-shows, changes in conditions, etc. Store records pertaining to an NEMT contract with Stearns County according to applicable state and federal requirements. Provide your procedures for investigating complaints and incidents related to the provision of NEMT services. C. List contracts you have in place for the provision of transportation services with other public or private entities. What are your expectations of transportation providers with whom you contract? D. Have any of your contracts with public entities been terminated or not renewed? If so, provide details. E. Provide a full description of the computer software and hardware you use for transportation coordination. Include claiming and billing, verifying eligibility, fraud prevention, handling/tracking calls, record storage, reporting to County and other entities, etc. F. Do you have expectations of County as a contracted entity regarding the provision of NEMT coordination? If so, please explain. G. Provide a copy of your organization s policies and procedures for NEMT coordination. H. Provide training materials used when hiring staff for NEMT coordination. I. Provide a sample report that you would provide to County detailing calls received and disposition of those calls, trips assigned, requests denied, complaints and disposition of complaints, trends and performance.
4 4 VI. BUDGET: Attach a budget for your proposed services to Stearns County for one year. VII. RATES: Provide proposed rates for services for Stearns County for each type of trip coordinated including one-way trips, client reimbursement, bus passes, volunteer driver rides, air and other special circumstances
5 5 VII. FINANCIAL RESPONSIBILITY Please answer the following questions. For purposes of this Section VII., the term you shall mean and include all partners, officers and directors, if any. A. Are your financial books and records audited by an independent accounting service? If Yes, please attach a copy of your most recent audit and management letter. B. Are all of your state and federal tax obligations, including payroll and income taxes, current? If No, please describe: Yes No C. If you have access to or responsibility for safeguarding client funds, please describe how you do so. If you do not have such access or responsibility, please so indicate. D. Are you presently debarred, suspended, ineligible or excluded from transacting business by or with any federal, state or local governmental department or agency? E. Within the past six years, have you been convicted of or had a civil judgment rendered against you for the commission of fraud or any criminal offense in connection with obtaining or performing a public contract? F. Within the past six years, have you been adjudicated a bankrupt or filed for relief in the United States Bankruptcy Court? G. Within the past six years, have you been or are you presently a party to a lawsuit or administrative proceeding related to the ownership and operation of your business? H. If you answered Yes to any of Questions D., E., F. or G., above, please describe (Use additional paper if required):
6 6 VIII. FINANCIAL MANAGEMENT AND INTERNAL CONTROL Check the appropriate answer to each Question. If the response is No, please explain in the Comments section. (Attach additional sheets, if necessary) Is there a formal accounting structure with chart of accounts established? Are accounting procedures reviewed at least annually and revised as necessary? Is there monthly monitoring of planned versus actual expense and obligation of funds to determine balances and possible overspending? Are numerical sequences of pre-numbered documents accounted for? Is it prohibited to issue checks to cash or bearer? Is it prohibited to sign checks in advance? Are disbursements, except those from petty cash, made by check? Are bank statements reconciled on a monthly basis? Are there policies or written documentation designating which individuals are authorized to sign time and attendance reports, etc.? Complete the following questions if you employ staff: Are accounting policies and procedures easily accessible by those required to follow those policies and procedures? Are there measures in place limiting unauthorized personnel from storage areas of such things as inventory, petty cash, blank checks, voided checks, etc.? Are employees who are authorized to deal with company funds bonded? Is it identified in writing who is authorized to sign checks and/or use signature stamp and/or complete wire transfers? Are all tax payments current, i.e. payroll taxes, sales tax, income taxes, Social Security, FICA,? Are all insurance premium payments current, including workman s compensation insurance premiums? Is the incoming mail opened by someone other than the person(s) having access to cash receipts or accounts receivable records? Are authorized check signers independent of check preparation, cash receiving and petty cash. Are bank reconciliations completed by someone other than persons participating in the receipt or disbursement of cash or those authorized to issue checks or handle cash. YES NO COMMENTS
7 7 CERTIFICATION I hereby certify that each answer set forth on this Applicant Proposal and all other information I have furnished is true and correct. I certify that I have the authority to submit this Proposal on behalf of the entity named herein. Dated: (Signature and Title) STEARNS COUNTY DEPARTMENT OF HUMAN SERVICES RESERVES THE RIGHT TO REQUIRE ADDITIONAL INFORMATION. SUBMISSION OF THIS PROPOSAL DOES NOT GUARANTEE A CONTRACT WITH STEARNS COUNTY.
8 8 LEAD COUNTY CONTRACT PREREQUISITES Attachment A As part of establishing a Lead County Contract a vendor must submit certain documents. These documents include but will not necessarily be limited to: 1) Proof of current insurance.* a) General liability covering an amount not less than $1,500,000 per occurrence. b) Professional liability covering personnel for the following amounts: $1,500,000 per occurrence if applicable. d) Workers Compensation Insurance as required by Minnesota state law including a certificate of compliance pursuant to Minnesota Statute e) Unemployment Compensation Insurance as required by law. 2) Proof of payment of all due taxes, penalties and interests. 3) Proof that person signing contract has authorization to execute contracts. * Stearns County must be covered as an additional insured by a vendor s general and professional liability insurance, in the amounts indicated above. Also, a standard indemnification clause will be part of the contract.
PROPOSAL FOR DRUG/ALCOHOL TESTING SERVICE Stearns County Human Services
PROPOSAL FOR DRUG/ALCOHOL TESTING SERVICE Stearns County Human Services INSTRUCTIONS: Please provide information as detailed below. Please write directly on this document, attaching additional pages as
More informationWright County Health & Human Services. Request for Proposals for Non- Emergency Medical Transportation
Wright County Health & Human Services Request for Proposals for Non- Emergency Medical Transportation Date of Publication: March 24, 2016 Americans with Disabilities Act (ADA) Statement: This information
More informationSAMPLE FINANCIAL PROCEDURES MANUAL
SAMPLE FINANCIAL PROCEDURES MANUAL Approved by (organization s) Board of Directors on (date) I. GENERAL 1. The Board of Directors formulates financial policies, delegates administration of the financial
More informationExample Accounting/Financial Policies
Example Accounting/Financial Policies TABLE OF CONTENTS INTERNAL CONTROLS... 2 ACCESS TO RECORDS BY MEMBERS... 3 ACCOUNTING COMPUTER FILE BACK-UP PROCEDURE... 3 ACCOUNTING METHOD... 3 AUDIT COMMITTEE...
More informationDIXON MONTESSORI CHARTER SCHOOL FISCAL CONTROL POLICY
DIXON MONTESSORI CHARTER SCHOOL FISCAL CONTROL POLICY 1. Purpose The Dixon Montessori Charter School Board of Directors ( Board ) has reviewed and adopted the following policies and procedures to ensure
More informationAPPLICANT INFORMATION (please print or type)
STATE OF MINNESOTA DEPARTMENT OF COMMERCE 85 7 TH PLACE EAST, SUITE 600 ST. PAUL, MINNESOTA 55101 (651) 539-1599 (For Department Use Only) DESIGNATED HOME STATE BUSINESS ENTITY INSURANCE ADJUSTER LICENSE
More information5:31-7 Appendix B LOCAL AUTHORITIES - ACCOUNTING AND AUDITING IF ANY ARE NOT APPLICABLE, INSERT N/A AS YOUR ANSWER. FIRE DISTRICT YEAR UNDER AUDIT
5:31-7 Appendix B LOCAL AUTHORITIES - ACCOUNTING AND AUDITING AUDIT QUESTIONNAIRE FOR FIRE DISTRICT AUDITS EACH QUESTION MUST BE ANSWERED. PLEASE CIRCLE YES OR NO. IF ANY ARE NOT APPLICABLE, INSERT N/A
More informationOctober 2007 Report No. 08-006. An Audit Report on The Medical Transportation Program at the Texas Department of Transportation
John Keel, CPA State Auditor An Audit Report on The Medical Transportation Program at the Texas Department of Transportation Report No. 08-006 An Audit Report on The Medical Transportation Program at the
More informationMINNESOTA DEPARTMENT OF HEALTH MASTER GRANT CONTRACT FOR COMMUNITY HEALTH BOARDS
MINNESOTA DEPARTMENT OF HEALTH MASTER GRANT CONTRACT FOR COMMUNITY HEALTH BOARDS DRAFT for Discussion Only 8.22.14 THIS MASTER GRANT CONTRACT, and amendments and supplements thereto, is between the State
More informationRequest for Proposals
City of Sonora Request for Proposals City of Sonora Microenterprise Technical Assistance Program Lead Technical Assistance Consultant City of Sonora Community Development Department 94 N. Washington Street
More informationBusiness Loan Application
Business Loan Application For LDC Staff Use Application received on: by Loan Program (s): 7/2015 BUSINESS INFORMATION Business Name: (Proposed or Existing) Loan Amount: $ Business Address: City County
More informationFINANCIAL CONTROLS POLICIES AND PROCEDURES FOR SMALL NONPROFIT ORGANIZATIONS
By Cindy Cumfer NOTE: These policies and procedures are designed for small nonprofits that do not have an administrator with financial expertise. They are set up to divide the fiscal control roles between
More informationAPPLICANT INFORMATION (please print or type)
STATE OF MINNESOTA DEPARTMENT OF COMMERCE 85 7 TH PLACE EAST, SUITE 600 ST. PAUL, MINNESOTA 55101 (651) 539-1599 (For Department Use Only) TRAVEL INSURANCE PRODUCER BUSINESS ENTITY LICENSE APPLICATION
More informationACCOUNTING POLICIES AND PROCEDURES SAMPLE MANUAL
(Name of Organization & logo) ACCOUNTING POLICIES AND PROCEDURES SAMPLE MANUAL (Date) Note: this sample manual is designed for nonprofit organizations with the following staff involved with accounting
More informationDRAFT AGREEMENT WITH THE COUNTY FOR ACCOUNTING AND PAYROLL SERVICES
DRAFT AGREEMENT WITH THE COUNTY FOR ACCOUNTING AND PAYROLL SERVICES Attachment 3 ATTACHMENT A FOR COUNTY USE ONLY New Change Cancel FAS Vendor Code epro Vendor Number SC Dept. A Contract Number epro Contract
More informationSALE OF CHECKS,TRANSMISSION OF MONEY LICENSE APPLICATION (Chapter 23, Title 5, Del.C.)
FOR OFFICE USE ONLY: Inv. Fee: Check No: Receipt No: STATE OF DELAWARE OFFICE OF THE STATE BANK COMMISSIONER 555 EAST LOOCKERMAN STREET SUITE 210 DOVER, DELAWARE 19901 SALE OF CHECKS,TRANSMISSION OF MONEY
More informationORDER AMENDING ACCOUNTING SYSTEM RULES FOR CIRCUIT COURTS
IN THE SUPREME COURT, STATE OF WYOMING OCTOBER TERM, A.D. 2013 In the Matter of the Amendment ) of the Accounting System Rules ) for Circuit Courts ) ORDER AMENDING ACCOUNTING SYSTEM RULES FOR CIRCUIT
More informationMEMORANDUM INTERNAL CONTROL REQUIREMENTS FOR NON-PROFITS
DIVISION OF CHILD CARE AND EARLY CHILDHOOD EDUCATION HEALTH AND NUTRITION UNIT P O BOX 1437, SLOT S 155 501-320-8982 FAX: 501-682-2334 TDD: 501-682-1550 TO: NON-PROFIT INSTITUTIONS FROM: HEALTH AND NUTRITION
More informationCHAPTER 4 EFFECTIVE INTERNAL CONTROLS OVER PAYROLL
CHAPTER 4 EFFECTIVE INTERNAL CONTROLS OVER PAYROLL INTRODUCTION AND LEARNING OBJECTIVES Every organization, including governments, require employees to assist in meeting their goals and objectives. The
More informationLICENSING PROCEDURES FOR MANAGING GENERAL AGENTS TO OBTAIN AUTHORITY IN VIRGINIA
LICENSING PROCEDURES FOR MANAGING GENERAL AGENTS TO OBTAIN AUTHORITY IN VIRGINIA October 2005 GENERAL INFORMATION The 1992 Virginia General Assembly passed legislation requiring the licensing of managing
More informationFABENS INDEPENDENT SCHOOL DISTRICT FABENS, TEXAS. REQUEST FOR PROPOSALS FOR CONSTRUCTION MANAGEMENT SERVICES (CM @ Risk) FOR
FABENS INDEPENDENT SCHOOL DISTRICT FABENS, TEXAS REQUEST FOR PROPOSALS FOR CONSTRUCTION MANAGEMENT SERVICES (CM @ Risk) FOR A New High School Competition Gym RFP No. 052015-036 PROPOSALS ARE DUE 10:00
More informationTravel Reimbursement Guide
Travel Reimbursement Guide MEDICAID TRANSPORTATION MANAGEMENT Personal Vehicle Mileage reimbursement is available, with prior approval from Medical Answering Services (MAS), to transport an eligible Medicaid
More informationState of Utah Department of Commerce Division of Consumer Protection
State of Utah Department of Commerce Division of Consumer Protection DEBT-MANAGEMENT SERVICES PERMIT APPLICATION FORM Annual Application Fee $250.00 (Non-refundable) Applicant s Name Date of Application
More informationINTERNAL ACCOUNTING CONTROLS CHECKLIST FOR NTMA CHAPTERS
P R E C I S I O N INTERNAL ACCOUNTING CONTROLS CHECKLIST FOR NTMA CHAPTERS Presented at NTMA 2004 Annual Convention Palm Springs, CA February 2004 National Tooling & Machining Association 9300 Livingston
More informationCarmel Unified School District. Prequalification Application For Bleacher and Pressbox Replacement Project at Carmel High School
Carmel Unified School District Prequalification Application For Bleacher and Pressbox Replacement Project at Carmel High School January 4, 2016 1 NOTICE REGARDING PREQUALIFICATION FOR BLEACHER AND PRESSBOX
More informationBUREAU OF INSURANCE STATE CORPORATION COMMISSION P.O. BOX 1157 RICHMOND, VA 23218
BUREAU OF INSURANCE STATE CORPORATION COMMISSION P.O. BOX 1157 RICHMOND, VA 23218 INSTRUCTIONS FOR COMPLETING THE INITIAL REINSURANCE INTERMEDIARY LICENSE APPLICATION GENERAL l. All responses except for
More informationSAI. DEFINED BENEFIT - 401(k) COMBO PLANS INSTALLATION KIT. Security Administrators, Inc.
SAI Security Administrators, Inc. 105 Court Street P.O. Box 1625 Binghamton, NY 13902-1625 (607) 771-1180 906 Spencer Street, Suite 200 Syracuse, NY 13204 (315) 474-8331 www.saiplans.com DEFINED BENEFIT
More informationEverest/WFGIA New Agent Contracting Set Up Sheet
Everest/WFGIA New Agent Contracting Set Up Sheet WFG Code # Agent s Name: Address: Apt./Suite No.: Phone Number: E-Mail Address: Checklist: Completed Producer History Sheet (9511) Contract (3357) signed
More informationDemographic Information. 17 Business Web Site Address 18 Business E-Mail Address ( ) -
(Please Print or Type) Check appropriate boxes for license requested. Resident License Non-Resident License o Identify Home State: o Identify Home State License #: New Application Additional Line(s) of
More informationPITTSBURG UNIFIED SCHOOL DISTRICT
PITTSBURG UNIFIED SCHOOL DISTRICT New Construction and Modernization Projects PRE-QUALIFICATION PROGRAM QUESTIONNAIRE FOR PROJECTS $20 MILLION AND OVER TABLE OF CONTENTS PAGE NO. GENERAL INFORMATION.......i
More informationNONPROFIT FINANCIAL MANAGEMENT SELF ASSESSMENT TOOL
NONPROFIT FINANCIAL MANAGEMENT SELF ASSESSMENT TOOL I. Financial Planning/Budget Systems 1. Organization has a comprehensive annual budget which includes all sources and uses of funds for all aspects of
More informationThe policy and procedural guidelines contained in this handbook are designed to:
BASIC POLICY STATEMENT The Mikva Challenge is committed to responsible financial management. The entire organization including the board of directors, administrators, and staff will work together to make
More informationCHAPTER 9 PRESCRIBED FORMS, TAXES, AND GENERAL INFORMATION
9-1 PRESCRIBED FORMS CHAPTER 9 PRESCRIBED FORMS, TAXES, AND GENERAL INFORMATION The State Board of Accounts is charged by law with the responsibility of prescribing and installing a system of accounting
More informationEmployment Application
Employment Application Please complete this application as completely and accurately as possible PERSONAL INFORMATION Today s Date Name: Last First Middle Social Security Number Address Home Telephone
More informationCARRIAGE MUSEUM OF AMERICA ACCOUNTING POLICIES AND PROCEDURES MANUAL. February 2014
CARRIAGE MUSEUM OF AMERICA ACCOUNTING POLICIES AND PROCEDURES MANUAL February 2014 I. Introduction The purpose of this manual is to describe all accounting policies and procedures currently in use at The
More informationCOLLECTION AGENCY ERRORS & OMISSIONS APPLICATION
APPLICANT S INFORMATION: COLLECTION AGENCY ERRORS & OMISSIONS APPLICATION Applicant Name: Business Name: Inspection Contact: Phone: Mailing Address: Insured Address: Same as above Business Website Address:
More informationAgent Agreement WITNESSETH
PATRIOT NATIONAL UNDERWRITERS, INC. Agent Agreement THIS AGENT AGREEMENT (the Agreement ) is made and entered into by and between Patriot National Underwriters, Inc., a Texas corporation ( Patriot ), and
More informationHow To Get A Collection Agency License In North Carolina
INSTRUCTIONS: Please refer to our Before You Begin handout. Complete all portions of this application for new licensure as a North Carolina collection agency. Responses to all requested information are
More informationTOM GREEN COUNTY BAIL BOND INDIVIDUAL SURETY LICENSE APPLICATION
New Application Renewal Application TOM GREEN COUNTY BAIL BOND INDIVIDUAL SURETY LICENSE APPLICATION **Submit Original & 14 Copies with filing fee to Tom Green County Treasurer** NO APPLICATION SHALL BE
More informationKINGSTON LUMBER SUPPLY COMPANY P.O. Box 169 Kingston, Washington, 98346 (360) 297-3600 or (206) 842-0104 Administration FAX: (360) 297-8391
KINGSTON LUMBER SUPPLY COMPANY P.O. Box 169 Kingston, Washington, 98346 (360) 297-3600 or (206) 842-0104 Administration FAX: (360) 297-8391 CONTRACTOR OR COMMERCIAL APPLICATION FOR CREDIT PLEASE COMPLETE
More informationAC 3290-S (Rev. 9/13) NEW YORK STATE VENDOR RESPONSIBILITY QUESTIONNAIRE FOR-PROFIT BUSINESS ENTITY
You have selected the For-Profit n-construction questionnaire which may be printed and completed in this format or, for your convenience, may be completed online using the New York State VendRep System.
More informationCertified Florida Community Service Provider (CFCSP)
Certified Florida Community Service Provider (CFCSP) APPLICANT INFORMATION Thank you for your interest in becoming a Certified Florida Community Service Provider (CFCSP) and member of Florida Community
More informationHillsborough County Aviation Authority Standard Procedure S250.06 Contractual Insurance Terms and Conditions
Hillsborough County Aviation Authority Standard Procedure S250.06 Contractual Insurance Terms and Conditions PURPOSE: To establish the insurance terms and conditions associated with contractual insurance
More informationREQUEST FOR PROPOSAL OFFICE OF THE NEVADA ATTORNEY GENERAL GRANTEE- FORECLOSURE RELIEF PROGRAM MAY 20, 2011
REQUEST FOR PROPOSAL OFFICE OF THE NEVADA ATTORNEY GENERAL GRANTEE- FORECLOSURE RELIEF PROGRAM MAY 20, 2011 SCOPE OF WORK: The Office of the Attorney General (AGO) recently received a settlement from Wells
More informationAppendix 1 CJC CONTRACT MANAGEMENT POLICIES AND PROCEDURES. Criminal Justice Commission Contract Management Policies and Procedures
CJC CONTRACT MANAGEMENT POLICIES AND PROCEDURES SNYOPSIS: The CJC was created by a Palm Beach County ordinance in 1988. It has 21 public sector members representing local, state, and federal criminal justice
More informationADDENDUM NO. 1 TO RFP 9600-61: Locum Tenens Referrals
ADDENDUM NO. 1 TO RFP 9600-61: Locum Tenens Referrals Date: March 18, 2015 To: All Vendors Interested in RFP # 9600-61 From: Kristen Aldrich, Deputy Purchasing Agent, NMC Contracts Division Subject: Addendum
More informationLegal Name of Applicant Website Tax ID Number
500 Virginia St. E. Ste 1200 Tel: 304.343.3000 Charleston, WV 25301 Toll-Free: 888.998.7642 P.O. Box 3697 Fax: 304.342.0985 Charleston, WV 25336-3697 www.wvmic.com Agency Address Producer Agent Information
More informationPREQUALIFICATION QUESTIONNAIRE
PREQUALIFICATION QUESTIONNAIRE BAW&G/WHW/JWF/172861.2 Revision Date: 01-14/14 1 Contractor Prequalification Package CONTACT INFORMATION Firm Name: Check One: Corporation (as it appears on license) Partnership
More informationSmall Business Enterprise Certification Application 49 CFR Part 26
Small Business Enterprise Certification Application 49 CFR Part 26 All firms wishing to be certified as a Small Business Enterprise (SBE) must complete this application and submit it to the Washington
More informationLIABILITIES. Cash on Hand and in Banks $ Outstanding Bills $ Savings Accounts $ Notes Payable to Banks and Others $
Small Business Loan Pool Application Page 1 of 5 (Rev. August 2010) Date: 5 AND 10 SMALL B USINESS L OAN F UND ECONOMIC DEVELOPMENT AUTHORITY OF FLOYD COUNTY SECTION I: GENERAL INFORMATION REQUEST FOR
More informationAGREEMENT FOR CONSULTING SERVICES (Sponsored Research) Consulting Agreement Number CA###-####-#### IIT PURCHASE ORDER NO. **
AGREEMENT FOR CONSULTING SERVICES () Consulting Agreement Number CA###-####-#### IIT PURCHASE ORDER NO. ** THIS AGREEMENT is made and entered into as of this day of, 20 (the Effective Date ) by and between
More informationWellsville Area Chamber of Commerce, Inc. Financial Policies and Procedures
Wellsville Area Chamber of Commerce, Inc. Financial Policies and Procedures The Wellsville Area Chamber of Commerce is committed to responsible financial management. All members of the organization (compensated
More informationNation Motor Club, LLC. 800 Yamato Road, Suite 100, Boca Raton, FL 33431 Tel: 561-226-3600 Fax: 561-226-3608
Nation Motor Club, LLC. 800 Yamato Road, Suite 100, Boca Raton, FL 33431 Tel: 561-226-3600 Fax: 561-226-3608 DELAWARE COVER SHEET Individual/Business Entity Licensing Requirements The State of Delaware,
More informationNew Mexico Office of Superintendent of Insurance Producer Licensing Bureau
PLEASE PRINT LEGIBLY OR TYPE Have you held an insurance license in any state within the last 5 years? Yes No If yes, identify the state Demographic Information 1 Soc. Security Number 2 If assigned, National
More informationINSURANCE REQUIREMENTS FOR VENDORS
INSURANCE REQUIREMENTS FOR VENDORS The Contractor/Vendor shall purchase and maintain for the duration of the contract/work insurance against claims for injuries to persons or damages to property which
More informationSTATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS
STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS Department of Business Regulation INSURANCE DIVISION 1511 Pontiac Avenue, Bldg. 69-2 Cranston RI 02920 Telephone No. (401) 462-9520 FAX No. (401) 462 9559
More informationIf No is selected above, provide a detailed explanation of any changes.
Attachment B Form FP-NMA Application Contact Information Provide the following information for the person who will be the primary contact for the Funding Portal ( FP ) Applicant during FINRA s review of
More informationFINANCE COMMITTEE PROCEDURES. Audit Process. Cash Handling
1 FINANCE COMMITTEE PROCEDURES Audit Process 1. Internal audits are conducted once a year. 2. The bookkeeper will provide the following information: bank statements, prior year vouchers, and access to
More informationSAN BERNARDINO MOUNTAINS COMMUNITY HEALTHCARE DISTRICT
SAN BERNARDINO MOUNTAINS COMMUNITY HEALTHCARE DISTRICT CONTRACTOR PRE-QUALIFICATION QUESTIONNAIRE 1 PRE-QUALIFICATION QUESTIONNAIRE 000 CONTACT INFORMATION Firm Name: Check One: Corporation (as it appears
More informationINTERNAL CONTROL QUESTIONNAIRE OFFICE OF INTERNAL AUDIT UNIVERSITY OF THE VIRGIN ISLANDS
Cabinet Member or Representative responsible for completing this form: INSTRUCTIONS FOR COMPLETING THIS FORM: Answer each question by placing an X in the either the Yes, No,, or Applicable () column. Provide
More informationFINANCIAL POLICIES INDEX
FINANCIAL POLICIES INDEX Page Accounts Payable 2 Cash Receipts 6 Credit Cards 9 General Ledger Adjustments 10 Fixed Asset 11 Payroll Tax Reporting 13 Travel Reimbursement 14 Handling Mail 15 1 Accounts
More informationChapter 21 Credit Services Organizations Act
Chapter 21 Credit Services Organizations Act 13-21-1 Short title. This chapter is known as the "Credit Services Organizations Act." Enacted by Chapter 29, 1985 General Session 13-21-2 Definitions -- Exemptions.
More informationChapter 7 Trustee. Internal Control Questionnaire
Chapter 7 Trustee Instructions for the trustee: The purpose of the (ICQ) is to provide the United States Trustee with an understanding of the internal controls and financial record keeping and reporting
More informationTHE MEDICAL PROTECTIVE COMPANY MULTI-SPECIALTY HEALTHCARE PROFESSIONAL PROFESSIONAL LIABILITY INSURANCE APPLICATION
APPLICATION INSTRUCTIONS If previously covered with Medical Protective, or joining a current Medical Protective Healthcare Professional group policy, please enter the Policy Number: THE MEDICAL PROTECTIVE
More informationSOUTH FLORIDA REGIONAL PLANNING COUNCIL REVOLVING LOAN FUND APPLICATION
Page 1 of 10 Applicant: SOUTH FLORIDA REGIONAL PLANNING COUNCIL REVOLVING LOAN FUND APPLICATION I. GENERAL INFORMATION Name of Individual completing this form: Title: Legal Business Name Type of Business:
More informationBUSINESS PRACTICE QUESTIONNAIRE (Credit Service Organization)
STATE OF NEVADA DEPARTMENT OF BUSINESS AND INDUSTRY DIVISION OF MORTGAGE LENDING 1830 College Parkway, Suite 100 Carson City, NV 89706 (775) 684-7060 Fax (775) 684-7061 www.mld.nv.gov BUSINESS PRACTICE
More informationFINANCIAL CASUALTY & SURETY, INC. ALLIANCE SURETY SERVICES PO Box 393, Greenville, SC 29602 \ Phone 864-232-4567 Fax 864-232-4467
FINANCIAL CASUALTY & SURETY, INC. ALLIANCE SURETY SERVICES PO Box 393, Greenville, SC 29602 \ Phone 864-232-4567 Fax 864-232-4467 APPLICATION FOR LIABLE BAIL Agency / Producer fcs The BAIL Insurance Company
More informationNOT ALL COMMUNITY SERVICES BLOCK GRANT RECOVERY ACT COSTS CLAIMED
Department of Health and Human Services OFFICE OF INSPECTOR GENERAL NOT ALL COMMUNITY SERVICES BLOCK GRANT RECOVERY ACT COSTS CLAIMED ON BEHALF OF THE COMMUNITY ACTION PARTNERSHIP OF NATRONA COUNTY FOR
More informationCeres Unified School District INDEPENDENT CONTRACTOR AGREEMENT 2013-2014
Ceres Unified School District INDEPENDENT CONTRACTOR AGREEMENT 2013-2014 THIS CONTRACT is hereby entered into by the Ceres Unified School District, hereinafter referred to as DISTRICT, and CONTRACTOR MAILING
More informationDEPARTMENT OF HEALTH CARE FINANCE
DEPARTMENT OF HEALTH CARE FINANCE Dear Provider: Enclosed is the District of Columbia Medicaid provider enrollment application solely used for providers, who request to be considered for the Adult Substance
More informationBerkeley Unified School District ROUTING FORM Contract, MOU and Amendment Approval
ROUTING FORM Contract, MOU and Amendment Approval All Independent Contractor Agreement, MOU and Amendment Forms should be routed to Purchasing Department first for tracking. Purchasing will send the documents
More informationSTATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS REQUIREMENT CHECKLIST FOR ALL RHODE ISLAND RESIDENTS:
STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS Department of Business Regulation INSURANCE DIVISION 111 Pontiac Avenue Bldg 69-2 Cranston, RI 02920 Telephone No. (401) 462-920 FAX No. (401) 462-9602
More informationFLORIDA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES
FLORIDA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES ADAM H. PUTNAM COMMISSIONER HOUSEHOLD MOVING SERVICES REGISTRATION APPLICATION Chapter 507, Florida Statutes Rule 5J15.001, Florida Administrative
More informationTHE GENESEE/SHIAWASSEE WORKFORCE DEVELOPMENT BOARD REQUEST FOR QUOTES FOR COMMERCIAL INSURANCE FOR THE PERIOD 2012-2015
THE GENESEE/SHIAWASSEE WORKFORCE DEVELOPMENT BOARD REQUEST FOR QUOTES FOR COMMERCIAL INSURANCE FOR THE PERIOD 2012-2015 QUOTE SHOULD BE SENT TO: Commercial Insurance Genesee/Shiawassee Michigan Works!
More informationLast Approval Date: May 2008. Page 1 of 12 I. PURPOSE
Page 1 of 12 I. PURPOSE The purpose of this policy is to comply with the requirements in Section 6032 of the Deficit Reduction Act of 2005 (the DRA ), which amends Section 1902(a) of the Social Security
More informationINFORMATION ABOUT COLLECTION AGENCY APPLICATION PROCESS
Oregon Department of Consumer and Business Services 350 Winter St. NE, Rm. 410, Salem, Oregon 97301-3881 Mailing address: P.O. Box 14480, Salem, OR 97309-0405 503-378-4140 Fax: 503-947-7862 http://dfcs.oregon.gov
More informationCHAPTER 267. BE IT ENACTED by the Senate and General Assembly of the State of New Jersey:
CHAPTER 267 AN ACT concerning third party administrators of health benefits plans and third party billing services and supplementing Title 17B of the New Jersey Statutes. BE IT ENACTED by the Senate and
More informationCity of Austin Application for Massage Therapy or Massage Establishment License City of Austin 500 4 th Avenue NE
OFFICE USE ONLY License No. Receipt No. City of Austin Application for Massage Therapy or Massage Establishment License City of Austin 500 4 th Avenue NE New License Renewal SECTION A. Applicant information
More informationApplication for Business Entity Insurance License (Please Print or Type)
Check appropriate boxes for license requested. Resident License Non-Resident License o Identify Home State: o Identify Home State License #: New Application Additional Line(s) of Authority Application
More informationSouth Carolina Department of Insurance Professional Bondsman / Runner / Surety Bondsman License Application
South Carolina Department of Insurance Professional Bondsman / Runner / Surety Bondsman License Application Staple a passport size full-face photograph of applicant here. Please check only one type of
More informationASSOCIATION OF AMHERST STUDENTS (AAS) Office of the Treasurer and Budgetary Committee
ASSOCIATION OF AMHERST STUDENTS (AAS) Office of the Treasurer and Budgetary Committee AGREEMENT FOR CONSULTING SERVICES This Agreement is made between the Association of Amherst Students (Association)
More informationAPPLICATION FOR THERAPEUTIC MASSAGE THERAPIST LICENSE
APPLICATION FOR THERAPEUTIC MASSAGE THERAPIST LICENSE CITY ADMINISTRATOR S OFFICE 1307 Cloquet Avenue, Cloquet MN 55720 Phone: 218-879-3347 Fax: 218-879-6555 www.ci.cloquet.mn.us email: djohnson@ci.cloquet.mn.us
More informationHow To Prevent Fraud On A Credit Card
Fraud Detection and Prevention Financial Management Advisory Council August 28, 2014 Sarah Mahugh, CPA, MBA Financial Audit Audit Manager Overview Fraud trends Fraud Risks and internal controls Case Studies
More informationA Municipal Checklist for Internal Control-Part I, Cash Controls
A Municipal Checklist for Internal Control-Part I, Cash Controls I. General Internal Control & Banking 1 Is a professional (independent) audit done annually? 2 If you have an annual audit was the most
More informationFLORIDA ATLANTIC UNIVERSITY COST-REIMBURSABLE SUBAWARD AGREEMENT #
FLORIDA ATLANTIC UNIVERSITY COST-REIMBURSABLE SUBAWARD AGREEMENT # This Cost Reimbursable Subaward Agreement is entered into in order to specify the terms and conditions under which Florida Atlantic University,
More informationJackson State University Athletics Compliance Department Athlete Agent Registration Application
Jackson State University Athletics Compliance Department Athlete Agent Registration Application I. Applicant General Information Companies with multiple applicants should complete a form for each person
More informationFalse Claims Act CMP212
False Claims Act CMP212 Colorado Access is committed to a culture of compliance in which its employees, providers, contractors, and consultants are educated and knowledgeable about their role in reporting
More informationATTACHMENT B FEDERAL CERTIFICATIONS FOOD SERVICE MANAGEMENT COMPANIES AND PUBLIC SCHOOLS
The undersigned states that: ATTACHMENT B FEDERAL CERTIFICATIONS FOOD SERVICE MANAGEMENT COMPANIES AND PUBLIC SCHOOLS 1. He or she is the duly authorized representative of the Vendor named below; 2. He
More informationSERVICES AGREEMENT. 2. Term. This Agreement will commence and expire. Medical Center Representative: Name and Title
This Services Agreement ( Agreement ) dated is made by and between [INSERT CONTRACTOR S NAME AND ADDRESS] (hereinafter called "Contractor"), and UMass Memorial Medical Center, Inc., Worcester, MA (hereinafter
More informationSAI NON-QUALIFIED PLAN INSTALLATION KIT. Security Administrators, Inc.
SAI Security Administrators, Inc. 105 Court Street P.O. Box 1625 Binghamton, NY 13902-1625 (607) 771-1180 906 Spencer Street, Suite 200 Syracuse, NY 13204 (315) 474-8331 www.saiplans.com NON-QUALIFIED
More informationREQUEST FOR QUALIFICATIONS PROPERTY APPRAISAL SERVICES. Prepared by. City of Richmond Finance Department. February 18, 2016 RESPONSES DUE:
REQUEST FOR QUALIFICATIONS PROPERTY APPRAISAL SERVICES Prepared by City of Richmond Finance Department February 18, 2016 RESPONSES DUE: 2:30 P.M., Monday, March 7, 2016 REQUEST FOR STATEMENTS OF QUALIFICATIONS
More informationFINANCIAL MANAGEMENT MANUAL
LAKE MICHIGAN AIR DIRECTORS CONSORTIUM FINANCIAL MANAGEMENT MANUAL This manual is the exclusive property of Lake Michigan Air Directors Consortium 9501 West Devon Avenue, Suite 701 Rosemont, Illinois 60018
More informationSmall Business Enterprises (SBE) Certification Application
Small Business Enterprises (SBE) SBE Certification Program Information and Application Mission Statement: The Office of Business Opportunity is committed to creating a competitive and diverse Business
More informationIRVINE UNIFIED SCHOOL DISTRICT. 100 Nightmist Irvine, California 92618 (949) 936-5317 CONTRACTOR S PREQUALIFICATION QUESTIONNAIRE, 20
100 Nightmist Irvine, California 92618 (949) 936-5317 CONTRACTOR S PREQUALIFICATION QUESTIONNAIRE, 20 The Irvine Unified School District ( District ) has determined that bidders on an annual basis must
More informationLICENSING REQUIREMENTS FOR SELF-SERVICE STORAGE INSURANCE
STATE OF TENNESSEE DEPARTMENT OF COMMERCE AND INSURANCE Insurance Division Agent Licensing 500 James Robertson Parkway Nashville, TN 37243-1134 Fax: 615 532-2862 615 741-2693 ce.agent.licensing@tn.gov
More informationBurleson Independent School District
Burleson Independent School District PTO/Booster Club Guidelines 11/1/2014 The following guidelines are to be used for student support activity groups (Parent Teacher Organizations, Booster Clubs, etc.)
More informationACCOUNTING AND FINANCIAL REPORTING REGULATION MANUAL
ACCOUNTING AND FINANCIAL REPORTING REGULATION MANUAL STATE BOARD OF ACCOUNTS 302 West Washington Street Room E418 Indianapolis, Indiana 46204-2769 Issued January 2011 Revised April 2012 TABLE OF CONTENTS
More information63rd Legislature AN ACT GENERALLY REVISING THE MONTANA DEFERRED DEPOSIT LOAN ACT; EXTENDING THE TIME
63rd Legislature HB0116 AN ACT GENERALLY REVISING THE MONTANA DEFERRED DEPOSIT LOAN ACT; EXTENDING THE TIME TO REQUEST A HEARING; ADDING PENALTIES INCLUDING FORFEITURE OF LOAN PRINCIPAL FOR LOANS MADE
More informationTHIS PAGE INTENTIONALLY LEFT BLANK
THIS PAGE INTENTIONALLY LEFT BLANK WINTON TRANSPORTATION, LLC NOW KNOWN AS UNIVERSAL TRANSPORTATION SYSTEMS, LLC BUTLER COUNTY TABLE OF CONTENTS Title Page Independent Auditor s Report... 1 Compliance
More informationVance County Schools Individual School Accounting
Individual School Accounting Internal Controls and Responsibilities Individual School Accounting Internal Controls and Responsibilities Contents Page Principal Statement of Understanding 3 Treasurer Statement
More information