Dental Services

New Hampshire Veterans Home
Appendix B - Transmittal Letter and Vendor Information
TRANSMITTAL LETTER
Solicitation ID Number
Vendor Name
Vendor Address
Vendor Telephone
State of NH Vendor Code
Number (required)
Date of Submission
We hereby submit this response to the Solicitation referenced above, in complete
accordance with all conditions and specifications set forth in the Solicitation.
We attest to the fact that:
1. The Vendor has read and fully understands this Solicitation and agrees to be
bound by its terms, conditions, and requirements.
2. The Vendor fully understands and agrees to items listed in Section 2 - Special
Provisions and Scope of Services and Appendix A - Form P-37 General
Provisions and Standard Exhibits.
3. The Vendor's Solicitation Response is effective for a period of 180 days from the
Vendor Solicitation Response Due Date or until the Effective Date of any resulting
Contract, whichever is later.
4. The prices, terms and conditions, and services in the Vendor's Solicitation
Response have been established without collusion with other vendors.
5. This document is signed by a person who is authorized to legally obligate the
responding Vendor.
Further, in accordance with RSA 21-I:11-c, the undersigned Vendor certifies that
neither the Vendor nor any of its subsidiaries, affiliates or principal officers is currently
debarred from performing work on any project of the federal government or the
government of any state.
Authorized Signature
Authorized Signature (printed)
Title
Telephone
Email
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New Hampshire Veterans Home
Appendix B - Transmittal Letter and Vendor Information
1. Vendor Contact Information
Primary Point of Name
Contact
Title
Individual who will
serve as the Vendor's
Email
primary contact for all
other matters relating Telephone
to the Solicitation.
Fiscal Contact Name
Individual who will
Title
serve as the Vendor's
primary contact for
Email
fiscal matters.
Telephone
2. Vendor References
Provide the information requested below for two (2) individuals or organizations who
have knowledge of your organization's capability to deliver services applicable to this
Solicitation. The Department may contact references at its discretion. A current
Department employee will not be considered a valid reference.
Vendor Reference 1
Individual/Organization
Name
Email
Telephone
Description of Work
Complete
Dates of Performance
Vendor Reference 2
Individual/Organization
Name
Email
Telephone
Description of Work
Complete
Dates of Performance
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New Hampshire Veterans Home
Appendix B - Transmittal Letter and Vendor Information
3. Affiliations - Conflict of Interest
Does your organization have any Choose an item.
affiliations that might result in a conflict
of interest in relation to this Solicitation?
a. If YES, explain the relationship(s)
and how the affiliation(s) would not
represent a conflict of interest.
4. Executive Summary
a. Provide a general company overview:
i. Describe the company's management, organizational structure, and
history; ownership and subsidiaries; company background and primary
lines of business; headquarters and satellite locations; mission statement;
and number of employees.
ii. Describe any strengths considered to be assets to the organization and
notable company accomplishments.
b. Provide an overview of the services the Vendor intends to provide.
i. Describe the organization's understanding of the services requested in
this solicitation and any problems anticipated in accomplishing the work.
ii. Identify years of service for general dentistry, years of service in geriatric
dentistry and years of service with on site services as an independent
contractor.
c. Bidders pricing response:
Bidder hereby offers to provide mobile dental services to the NHVH in accordance with all of the
requirements of this bid at the following prices for the entire contract term.
Year 1 (Total amount invoiced monthly) $ x 12 months = $
Year 2 (Total amount invoiced monthly) $ x 12 months = $
Year 3 (Total amount invoiced monthly) $ x 12 months = $
Total not to exceed amount $
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