RFA #34301-40825 Dementia CARE Application

Applicant Information

1. Organization Name: *This question is required.

2. Primary Contact Person: *This question is required.

3. Secondary Contact Person:

4. Organizational Address: *This question is required.

5. Do you propose to use subcontractors for any portions of the scope of services? *This question is required.

6. If yes, please provide the name and address of each subcontractor and what specific services each will perform.

6. Select one (1) of the following as it applies to this application: *This question is required.

7. Please attach details of requested modifications to the sample contract.