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EXHIBIT C <br />CITY OF SANTA ANA <br />REQUEST FOR PROPOSALS FOR MEDICAL SERVICES REVIEW PROGRAM <br />PROPOSERS CERTIFICATION and PROPOSAL ITEM PRICING <br />Certification - I certify that I have read, understand and agree to the terms and conditions of this Request for <br />Proposals. I have examined the Scope of Services (Exhibit A) and am familiar with the scope of work locations. <br />I am familiar withiall the existing conditions and limitation that may impact work requests. I understand and <br />agree that I am responsible for reporting any errors, omissions or discrepancies to the City for clarification prior <br />to the submission of my proposal. <br />Proposal Item Price - Pricing shall be based on the services performed, for services described in Exhibit A. <br />Fee must be inclusive of all costs, including but not limited to, direct and indirect costs for labor, overhead, <br />incidental supplies, travel, mileage, and fuel. Attach additional pages as needed. <br />ESTIMATED COST PER ESTIMATED. <br />TYPE OF MEDICAL PROCEDURE # OF TESTS TEST TOTAL COST <br />LEGAL NAME OF COMPANY PHONE AND FAX NUMBERS <br />BUSINESS ADDRESS <br />PRINTED NAME OF AUTHORIZED AGENT <br />SIGNATURE OF AUTHORIZED AGENT <br />FEDERAL ID NUMBER (IF APPLICABLE) <br />DATE <br />TITLE <br />E-MAIL ADDRESS <br />CONTRACTOR LICENSE NUMBER (IF APPLICABLE) <br />THIS FORM MUST BE COMPLETED AND INCLUDED WITH THE PROPOSAL. <br />PROPOSALS THAT DO NOT CONTAIN THIS FORM WILL BE CONSIDERED NONRESPONSIVE. <br />for Medical Services Review—August 27, 2018 <br />2P tt6 <br />