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State of Cali forma—DepartmeneofGeneral Service; Procurement Division Solicitation Number 84049 <br />GSPD-05-105 (REV 08/091 - <br />BIDDER DECLARATION <br />1. Prime bidder information (Review attached Bidder Declaration Instructions prior to completion of this form): <br />a. Identify current California certification(s)(MB, SB, <br />, NV5A, DVBE): or None i•' (IY'None,go to Item#2) <br />b. Will subcontractors be used for this contract7 Yes 0 No0(if yes, indicate the distinct element of work your firm will perform in this contract <br />e.g., list the proposed products produced by your firm, state if your firm owns the transportation vehicles that will deliver the products to the State, <br />identify which solicited services your firm will perform, etc.). Use additional sheets, as necessary. <br />Grant oversight & Fiscal Agent coordination with sub cQntractors and partners, ca a management aaaessment training OJTIWEX <br />and support services. I� , <br />c. If you are a California certified DVBE: (1) Are you a broker or agent? Yes t_I No l v I. <br />(2) If the contract includes equipment rental, does Kour company ca at least 51% of the equipment <br />provided In this contract (quantity and value)? Yes No N/A ✓ <br />2, If no subcontractors will be used, skip to certification below. Otherwise, list all subcontractors for this contract. (Attach additional pages if necessary): <br />Subcontractor Name, Contact Person, <br />Subcontractor Address <br />(A Ceffification(MB,S6, <br />Work performed or goods provided <br />Corresponding <br />Good <br />51% <br />Phone Number& fax Number <br />&Emall Address <br />NVSA, DVBE or None) <br />for this contract <br />%of bid price <br />Standing? <br />Rental? <br />City of Anaheim <br />Flores <br />201 S. Anaheim Blvd. <br />Suite 1001 <br />None <br />Coordination of Services - Case <br />25% <br />El <br />714-765- <br />Management, Assessment, <br />9 <br />Fax 714-765-65-4356 <br />Anaheim CA 92805 <br />Training, OJT and support <br />Iflores@anaheim.net <br />services <br />County of Orange <br />Lacy <br />1300 S. Grand Ave <br />Bldg. B, 3rd FI. <br />None <br />Coordination of services - Case <br />Management, Assessment, <br />20% <br />El <br />714-480-6420 <br />Santa Ana CA 92705 <br />Training, OJT, and support _ <br />Fax 714-834-7132 <br />carma.lacy@occr.ocgov.com <br />services <br />Working Wardrobes <br />Jerri Rosen <br />1861 Kettering St <br />Irvine, CA 92614 <br />None <br />Case Management, workforce <br />15% ' <br />❑ <br />❑ <br />readiness training, soft skills, job <br />714-210-2460 <br />jerd@workingwardrobes.org <br />development and placement, <br />Fax 714-434-2870 <br />interviewfwork wardrobe <br />CERTIFICATION: By signing the bid response,l certify under penalty of perjury that the information provided is true and correct. <br />pace 1 of 2 <br />