Purpose of Sub-Grant:

State of ArkansasARKANSAS DEPARTMENT OF HEALTH

4815 West MarkhamLittle Rock, Arkansas 72205

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Application Packet

APPLICATION SIGNATURE PAGE Type the following information.

APPLICANT’S INFORMATION Company (as listed with IRS) with dba if applicable

Federal Tax-ID# AASIS Vendor Number (if known)

Is your Company 501(c) 3 Nonprofit? □ Yes □No If, yes, your IRS designation letter must be submitted

Your Agency Fiscal Year Dates:

Address: P.O. Box

City: State: Zip Code:

Business Designation:

□ Individual □ Sole Proprietorship □ Public Service Corp

□Partnership □ Corporation□ Nonprofit□Intergovernmental

Minority and Women- Owned Designation: *

□Not Applicable

□African American

□ American Indian □ Asian American □Service-Disabled Veteran

□ Hispanic American □ Pacific Islander American□Women-Owned

AR Certification #: * See Minority and Women-Owned Business Policy

APPLICANT CONTACT INFORMATION Provide contact information to be used for bid solicitation related matters.

Contact Person: Title:

Phone: Alternate Phone:

Email:

Alternate Email:

ILLEGAL IMMIGRANT CONFIRMATION

By signing and submitting a response to this solicitation, the applicant agrees and certifies that they do not employ or contract with illegal immigrants. If selected, the recipient certifies that they will not employ or contract with illegal immigrants during the aggregate term of a contract.

ISRAEL BOYCOTT RESTRICTION CONFIRMATION

By signing and submitting a response to this solicitation, the applicant agrees and certifies that they do not boycott Israel, and if selected, will not boycott Israel during the aggregate term of the contract. Geographical Coverage Area: Indicate geographical coverage area as either statewide or by individual counties, alphabetically.

An official authorized to bind the prospective recipient to a resultant contract shall sign below.

By signing and submitting a response to this Notice of Funds Availability (NOFA), the applicant agrees to comply with all requirements, and that any exception that conflicts with a requirement of this NOFA will cause the application to be disqualified.

Authorized Signature: Title: Use Ink Only.

Printed/Typed Name: Date:

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PROPOSED SUBCONTRACTORS FORM • Do not include additional information relating to subcontractors on this form or as an attachment to this form.

PROSPECTIVE CONTRACTOR PROPOSES TO USE THE FOLLOWING SUBCONTRACTOR(S) TO PROVIDESERVICES.

Type or Print the following information

Subcontractor’s Company Name Street Address City, State, ZIP

☐ PROSPECTIVE CONTRACTOR DOES NOT PROPOSE TO USE SUBCONTRACTORSTO PERFORM SERVICES.

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INFORMATION FOR EVALUATION

Provide a response to each item/question in this section. Prospective Contractor may expand the space under eachitem/question to provide a complete response.

Do not include additional information if not pertinent to the itemized request.

Maximum Raw

Score Available

E.1 Proposal Narrative

1.

For each service criteria area applied for, indicate the pillar the model addresses and clearly describe the proposed model your organization will implement within the state and how activities will be carried out/accomplished.(If applying for funding for more than one activity ensure to show indication of narrative information (E1.1, E1.2, and E13) for each activity.)

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2. Describe what populations and sub-populations the model will serve and what areas of the state.

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3. Describe how your organization will secure protected health information. 5

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E.2 Organizational Capacity

1.

Describe your organization’s capacity for implementing and carrying out the proposed activities. Ensure to discuss key roles currently within your organization and their efforts to the activities and new roles to be established for the activities.

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2. Describe what cost effective methods you shall deploy to be good stewards of funding award and the fiscal structure of your organization.

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3. Describe your organization’s information technology structure. 5

4. Describe your organization’s ability to collect data and submit reporting. 5

5. Describe what technical assistance you will need from the ADH. 5

E.3 Work Plan

1. Complete attached “Work Plan” detailing information requested in template. 10

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E.4

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