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state of alifornia—Department ofGeneni SerAsom Procurement Division solicitation Number 84049 <br />GSPD-0S-tos [gEVOB/09i <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)(MR, SO, NVSA, DVBE):_„_.,—,_ or None i. i (If"None;goto Item#2) <br />Is. Will subcontractors be used for this contract? Yes O✓ No 0 (if yes, Indicate the distinct element of work ygur 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 §A contractors and_part� case management ssessment training O IT/WEE <br />and support services. I —I I �I <br />c, If you area California certified DVBE: (1) Are you a broker or agent? YesNoG <br />(2) If the contract includes equipment rental, does yo rcofganyoww at least 51% of the equipment <br />provided in this contract(quantity and value)?Yes IN N/A ✓ <br />2, If no subcontractors will be used, skip to certification below. Otherwise, list all subcontractors for this contract. (Attach additional pages it ne�assarvl• <br />Subcontractor Name,ConvxtPerson, <br />- StilicOnti Address <br />CA Certifxation(0,SB, <br />Work performed or goods provided <br />Conespondmq <br />Good <br />51% <br />Phone Number &Fax Number <br />&Email Address <br />WSA,I)VIlEmNone) <br />forthismntrad <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 />- <br />Coordination of Services - Case <br />Management, Assessment, <br />25% <br />El <br />714-765-4341 <br />Fax 714-765-4356 <br />Anaheim CA 92805 <br />Training, OJT and support <br />Iflores@anahelm.nel <br />services <br />County of Orange <br />Carma Lacy <br />1300 S. Grand Ave <br />Bldg. B, 3rd FL <br />None <br />Coordination of services - Case <br />Management, Assessment, <br />20% <br />❑ <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 />1851 Kettering St <br />None <br />Case Management, workforce <br />- <br />Jerri Rosen <br />Irvine, CA 92614 <br />readiness training, soft skills, job <br />15% <br />❑ <br />714-210-2460 <br />jerri@workingwardrobes.org <br />development and placement, <br />Fax 714-434-2870 <br />- <br />Interviewhvork wardrobe <br />CERTIFICATION: By signing the bid response, I certify under penalty of perjury that the information provided is true and correct. <br />Page o of <br />