Re-qualification Form

Re-qualification Form and Agreement

Recitals

WHEREAS, Applicant Name: (the "Applicant") was previously granted qualification under Qualification ID: on ;

WHEREAS, Applicant seeks re-qualification for continuing eligibility to perform services or receive benefits under the terms and criteria of the Re-qualification Program described herein;

WHEREAS, Administrator Name: (the "Administrator") will review, evaluate and make a determination in accordance with the provisions of this Re-qualification Form and Agreement.

Applicant Information

Individual    Corporation    LLC    Partnership    Other:

Scope of Re-qualification

Describe the categories, services, or capabilities for which re-qualification is requested and any limitations or special conditions to be considered by the Administrator.

Attachments and Supporting Documents

Applicant must submit the documents indicated below with this Form. Check all that are included and provide brief descriptions where requested.

Current qualification certificate or license
Proof of insurance (coverage details):
Most recent financial statements
Client references (list attached)
Other:

Representations, Warranties and Certifications

By submitting this Form, Applicant certifies that the statements and documents provided are true, accurate and complete. Applicant further represents that it is not debarred, suspended, or otherwise ineligible under applicable procurement or grant regulations, and that Applicant will promptly notify Administrator of any material change in circumstances.

Applicant certifies that the information provided is complete and accurate.
Applicant is not debarred or suspended from contracting with public or private entities.
Applicant will comply with applicable laws, regulations, and contractual requirements.

Payment Terms

A non-refundable re-qualification fee, if applicable, shall be paid in accordance with the following terms.

Term and Termination

This re-qualification shall commence on Start Date: and shall expire on End Date: unless earlier terminated in accordance with this Agreement.

Either party may terminate for convenience by providing written notice at least days prior to the intended termination date. Administrator may terminate immediately for cause upon material breach, fraud, or loss of required licensure or insurance.

Confidentiality

Each party shall maintain in confidence all non-public information disclosed in connection with this re-qualification, shall use such information solely for purposes of evaluation and performance under this Form, and shall not disclose such information to third parties except as required by law or with prior written consent. Confidential information does not include information that is or becomes publicly available without breach.

Governing Law

This Re-qualification Form and Agreement shall be governed by and construed in accordance with the laws of the jurisdiction specified below.

Entire Agreement

This Form, together with any attachments and supporting documents incorporated by reference, constitutes the entire agreement between Applicant and Administrator with respect to re-qualification and supersedes all prior proposals, representations, and agreements, whether written or oral, concerning the subject matter herein. Any amendment must be in writing and signed by both parties.

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