METROPOLITAN COMMUNITY COLLEGE
Health Science Institute
3200 Broadway Kansas City, MO 64111
REQUEST FOR PROPOSAL # 16-7131-C3R2 (RFP)
NURSING TESTS
RFP FORMS TO BE FILLED OUT AND RETURNED WITH PROPOSAL
PROPOSAL FEE SCHEDULE FORM
Services
Nursing Tests
Price
By signing below, I am certifying that I am submitting this proposal as an authorized
representative of the below-named contractor, have thoroughly reviewed and understand the
terms and conditions of the RFP, and am submitting the proposal accordingly.
Dated this
day of
, ____.
(Authorized Representative Signature)
(Authorized Representative Name/Title)
(Company Name)
(Address)
(City, State, Zip)
(Phone Number/Fax Number)
(Email Address)
THIS FORM MUST BE COMPLETED AND SUBMITTED WITH THE RFP.
©2015 Metropolitan Community College
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[Name of Project]
MBE/WBE PARTICIPATION FORM
If proposing MBE/WBE participation, the contractor must indicate below the percentage of
qualified MBE and WBE participation committed to in relation to the total dollar value of the
contract regardless of whether the contractor is awarded one, some or all of the categories
being proposed. Overall, the MBE and WBE participation must not be contingent upon
award of a specific category and the contractor, if awarded a contract, must be able to
achieve the stated participation for the resulting contract regardless of the categories awarded
or not awarded. The contractor must be able to achieve participation stated below for the
total value of the awarded contract(s). If the contractor is a qualified MBE and/or WBE,
the contractor may indicate 100% participation.
The contractor is committed to the following MBE and WBE participation on this RFP:
Total MBE Participation
% Total WBE Participation
%
Complete the following table indicating the firms used to meet the participation levels indicated.
MBE Firm Name
MBE % of
Contract
WBE Firm Name
WBE % of
Contract
THIS FORM MUST BE COMPLETED AND SUBMITTED WITH THE RFP.
©2016 Metropolitan Community College
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FEDERAL WORK AUTHORIZATION PROGRAM (“E-VERIFY”) ADDENDUM
For Contracts with The Junior College District of Metropolitan Kansas City, Missouri aka
Metropolitan Community College, a public community college district and political subdivision of
the State of Missouri (“MCC”). Pursuant to Missouri Revised Statute 285.530, all business
entities awarded any contract in excess of five thousand dollars ($5,000) with a Missouri political
subdivision must, as a condition to the award of any such contract, be enrolled and participate in
a federal work authorization program with respect to the employees working in connection with
the contracted services being provided, or to be provided, to MCC (to the extent allowed by EVerify). In addition, the business entity must affirm the same through sworn affidavit and
provision of documentation. In addition, the business entity must sign an affidavit that it does
not knowingly employ any person who is an unauthorized alien in in connection with the
services being provided, or to be provided, to MCC.
Accordingly, your company:
(a)
Agrees to have an authorized person execute the attached “Federal Work Authorization
Program Affidavit” and deliver the same to MCC prior to or contemporaneously with the
execution of its contract with MCC;
(b)
Affirms it is enrolled in the “E-Verify” work authorization program in the United States,
and is participating in E-Verify with respect to your employees working in connection with the
services being provided (to the extent allowed by E-Verify), or to be provided;
(c)
Affirms that it is not knowingly employing any person who is an unauthorized alien in
connection with the services being provided, or to be provided, by your company to the district.
(d)
Affirms you will notify MCC if you cease participation in E-Verify, or if there is any action,
claim or complaint made against you alleging any violation of Missouri Revised Statue 285.530,
or any regulations issued thereto;
(e)
Agrees to provide documentation of your participation in E-Verify to MCC prior to or
contemporaneously with the execution of its contract with MCC (or at any time thereafter upon
request by MCC), by providing to MCC an E-Verify screen print out (or equivalent
documentation) confirming your participation in E-Verify;
(f)
Agrees to comply with any state or federal regulations or rules that may be issued
subsequent to this addendum that relate to Missouri Revised Statute 285.530; and
(g)
Agrees that any failure by your company to abide by the requirements a) through f)
above will be considered a material breach of your contract with MCC.
By:
(Signature)
Name and Title:
For and on behalf of:
(Company)
THIS FORM MUST BE COMPLETED AND SUBMITTED WITH THE RFP.
©2016 Metropolitan Community College
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Nursing Tests
FEDERAL WORK AUTORIZATION PROGRAM AFFIDAVIT
I, ___________________, being of legal age and having been duly sworn upon my oath,
state the following facts are true:
1.
I am more than twenty-one years of age; and have first-hand knowledge of the
matters set forth herein.
2.
I am employed by _______________________________(“Company”) and have
authority to issue this affidavit on its behalf.
3.
Company is enrolled in and participating in the United States E-Verify federal
work authorization program with respect to Company’s employees working in connection with
the services Company is providing to, or will provide to MCC, to the extent allowed by E-Verify.
4.
Company does not knowingly employ any person who is an unauthorized alien in
connection with the services Company is providing to, or will provide to, the MCC.
FURTHER AFFIANT SAYETH NOT.
By:
(Signature)
Name/Title:
On Behalf of:
(Company)
STATE OF ___________ )
) ss.
COUNTY OF __________)
Submitted and sworn to before me this ____ day of _______ , 201___.
__________________________________
Notary Public
__________________________________
Print Notary Name
My commission expires:
THIS FORM MUST BE COMPLETED AND SUBMITTED WITH THE RFP.
©2016 Metropolitan Community College
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ACKNOWLEDGEMENT OF RECEIPT
This Form Must be Completed and Emailed/faxed Upon Receiving
Request for Proposal #16-7131-C3R2 (RFP)
NURSING TESTS
Please fill in the requested information below and return to the Purchasing Department, as
acknowledgement that you have received the Request for Proposal noted above. This is not
required but by submitting this form, we will be able to provide notification of any
addenda to the RFP.
Metropolitan Community College Purchasing Department
Email to: purchasing.info@mcckc.edu
Or Fax: 816-759-1221
By doing this, we will be able to provide notification of any addenda to the RFP.
Name of Firm:
Address:
City/State/Zip:
Phone:
Fax:
Name: (Print)
Title:
Email address:
Signature:
Date:
☐
Yes, our company does have an interest in responding.
☐
No, our company does NOT have an interest in responding.
Submit this form to MCC prior to 10:00 AM on May 5, 2016.
(Proposals can still be submitted even if this form has not been sent to MCC prior to this date.
Please check www.mcckc.edu/purchasing/bids for revisions or addenda that may not have been
received.)
©2016 Metropolitan Community College
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