HomeMy WebLinkAbout28700CONTRACT INFORMATION SHEET
DATE: 10/28/16
Contract No.: P-16-601-P Vendor Number:
Contract Title: Work Experience & Name/Address:
Supervised Training
Contract Period: 10/01/16 -09/30/17 Representative:
Using Agencies: 5610 Phone No.:
Email:
Terms: N45 ---------------------
Total Contract Amt.: $0.00 ~~~--------------
Buyer Name: Debbie Scharnick
Requisition No: _5_61_1_7_0_03_3_3 _______ _ Org: 56107001
Supersedes:
.__ _ __,\ RENEWAL L.--.....J~ ADJUSTMENT OONEW
D TICKDATE .___.....JI REFERENCE (RFQ# I RFP#)
DESCRIPTION: Work Experience Activities & Supervised Work Training
Vendor: Habitat for Humanity Fresno inc.
0000258832
Purchasing Master
Agreement
RFSQ 17-023
SPECIAL INSTRUCTIONS: One year contract-May be extended for two additional one year periods by mutual consent.
DISTRIBUTION:
DEPARTMENT: _D_SS ______ _
REQUISITIONER: Jessica Rangel
Dean Brawley
Rev l/2/15
Completed By: Date: Completed By: Date
PROCUREMENT AGREEMENT NUMBER: P-16-601-P
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October 3, 2016
CONTRACTOR TO COMPLETE:
Company: /Ti ::>;/ ;G)' ?~-
Type of Entity:
0. Individual
0 Sole Proprietorship
l;n Corporation
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Print Name and.TiUe
Signature (In Blue Ink):
Print Name and Title
Signature (In Blue Ink):
Address
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0 Limited Liability Company
0 Limited Liability Partnership
0 General Partnership
Date
Date
City State Zip
TELEPHONE NUMBER FAX NUMBER E-MAIL ADDRESS
ACCOUNTING USE ONLY
ORG No.: 5610/7001
Account No.: 7870
Requisition No.: 5611700333
(09/2015)
G:\PUBUC\CONTRACTS & EXTRACTS\P\P~l6~60l~P M<\STER AGREEMENT.DOCX
Page 5
Issuance Date:
Closing Date:
Submittals:
Addressed To:
Mailing Address:
Mark Envelope:
Cost Limit for
Agreement(s):
REQUEST FOR STATEMENT OF QUALIFICATIONS
NO. 17-023
COUNTY OF FRESNO
Work Experience Activities and
Supervised Work Training
September 29, 2016
Wednesday, October 12,2016 2:00P.M.
Two (2) paper copies of the Statement of Qualifications
Debbie Scharnick, Purchasing Technician I
County of Fresno, Purchasin~
4525 E. Hamilton Avenue, 2° Floor
Fresno, CA 93702
"RFSQ -Work Experience Activities and Supervised Work Training"
No Cost to Vendors
STATEMENT OF QUALIFICATIONS (SOQ) PACKAGES RECEIVED AFTER THE TIME AND DATE
STATED ABOVE WILL BE RETURNED UNOPENED TO THE VENDOR.
Inquiries and Updates: Requests for clarification regarding this Request for Statement of Qualifications
(RFSQ) must be submitted in writing via email to Debbie Scharnick, Purchasing Technician I, at
dscharnick@co.fresno.ca.us, and received by the County no later than 10:00 A.M., Tuesday, October
4, 2016. Such information as is reasonably available and will facilitate preparation of responses hereto,
requests for clarification and associated responses, and any addenda to this RFSQ will be posted at:
Lill!~.!J!!!j~~=~~~~~L:::~~~i2!.':~::::::!.!.E~~~~-~~""'~.!S!lb and will not otherwise be distributed.
Organization
Individual/Contact Person Title
Street Address/P .0. Box -f·,:Z§J y~ (!
City
Fax Number E-Mail Address
17-023
Work Experience/Communty Service Qualification Survey Attachment A
Employer Name:
lf/J&;, _A r
Address:
I-· c;.y I
ctti
Contact Person:
Phone Number:
Employer Category:
J/1; c:.. !ii ?\./ L C 'f 4-tJ£ ·flt.;. 3 0_ Private Non-profit*
Zip Code: rt1-Public Non-profit*
f~ .-1".-./ r.;'-*:.......,._; '--v v, v,.l
Extension:
( ss·y ) ?J ._, -~-;o .-
~ -Fax Number:
r .-· .~-· ~ \
Type of Service to be Provided: ttl Work Experience IS~r Community Service
.'
Worksite Location
Address: Worksite Supervisar.
-7<"'17 / /t1 -~~,--;-;!'.,?. . ."('
City:
Extension:
Job Title: Duties to be Performed:
2/
I
Minimum Requirements for the Position:
L ,·n7
--
r'£ti.. vv ;Tt/ Vz!li!N7tG 'L__,
<~
length of Project:
L.
Weekly Hours Available (Maximum 40 hours/week): Special Clothing I Equipment Requirements:
((!v
Worksite Supe~61'-SigQ~ture:
-------~~
. / """'~
Date: .
r;;£ r6
17-023
Work Experience/Communty Service Qualification Survey Attachment A
Employer Category:
. ft
1
. ., _ 0 PriVate Non-profit* 4=.Y4 I £ l"i-1 c.. /L;P\./[ ,-:;._ )' 4 J£ ,<:7-_5 I-C-Ity-T:--.:...-t-~-=-..;.._.:...::::~..!......._;;_:,;,..;;Z;....i..£,.p_C_o_de+1 :..~.<:.-..;::;_---=---1 ~ Public Non-profit*
F12./.£.s~'l/ ;; f;? / ..;;--? 0 Private Business ~---~~~~~~-----------~--~~-4~~----1
Contact Person: *Must provide SOl( c) (3}
--T:::?._r.-0 ,:~ c C' J,rv·r
Phone Number: Extension: ,. ' i §Sf) /37-'-//0: ·
F'ax Number:
{ ~-<. \ "'::./
Type of Service to be Provided: ftl Work Experience L)'4-Community Service
Worksite Location
Address:
City:
Job Title:
e-r;/L
Minimum Requirements for the Position:
length of Project:
Worksite Supervisor:
/Yl ?7-'JZ-G_tC;_ &-\.)
Phone Number:
Extension:
Duties to be Performed:
i
i.> ('/
L T
Weekly Hours Available (Maximum 40 hours/week): Special Clothing I Equipment Requirements:
Worksite Supe~sor.Sis_~ature: Date:
._----~-·-
Work Experience/Communty Service Qualification Survey
Employer Name: Employer Category:
0 Private Non-profit*
0 Public Non-profit*
? 3 J,_) 0 Private Business
r---~------~--------------L-----------~----~ Contact Person: *Must provide SOl(c) (3)
Extension:
Type of Service to be Provided: fl1 Work Experience IZ:J Community Service
Worksite Location
Address: Worksite Supervisor:
Zip Code: Extension:
Job Title: Duties to be Performed:
Minimum Requirements for the Position:
'"'_,_, ..... :
Length of Project:
Weekly Hours Available (Maximum 40 hours/week): Special Clothing I Equipment Requirements:
/
Worksite Supervis~ature: Date:
-~----__.,--~---..-.. _-.--.::
17-023
Attachment A
Work Experience/Communty Service Qualification Survey
Employer Category:
Contact Person:
Extension:
Type of Service to be Provided: ttl Work Experience IS:l Community Service
f
Worksite location
Address: Worksite Supervisor:
/ ', .'3 / -·~--~? 1 I ~/ ~~;:..:. ( , .. , .. i
City: Phone Number: t· 6!
; I '2'-· Extension:
Job Title: Duties to be Performed:
Number of Positions Available:
6
Minimum Requirements for the Position:
Length of Project:
I
6
Weekly Hours Available (Maximum 40 hours/week): Special Clothing I Equipment Requirements:
17-023
Attachment A
lTd
17-023
Work Experience/Communty Service Qualification Survey Attachment A
Employer Name: Employer Category:
. .rr-0 Private Non-profit* ¥ cf 9! £ ;1; c.. fL;fJ L .~ 'f 4 ;£ ·{.;. 3 1-C-ity-f.:--"--'-.::..--=-..;.__:...=..:.......£...,;.-=-::;,.::Z;...i~p-C-od-e+, :...s.:::.;-=---=----1 55 Public Non-profit*
rf2.;::£ :S:'I} /) 7 j 7 > / 0 Private Business ~~~~~~~----------~--~~~~~--~
Contact Person: *Must provide 501(c} (3}
~:2-.r.--...J /S. [ t ;_/.''<.//
Phone Number: Extension:
( SS'Y) ;J-J.
Fax Num-ber:
r ·')· S / \ e../ 5-l ·-0 / 7~
Type of Service to be Provided: ttl Work Experience l2f Community Service
I
Worksite Location
Address: Worksite Supervisor:
~·;·~'
// ~) • .:.:.._ ;-..<-I\;
Phone Number:
Zip Code: Extension:
JobTrt:le: Duties to be Performed:
Minimum Requirements for the Position:
[.' v
Weekly Hours Available (Maximum 40 hours/week): Special Clothing I Equipment Requirements:
Worksite Su~ignature:
17-023
Work Experience/Communty Service Qualification Survey Attachment A
Employer Category:
Contact Person:
Phone Number: Extension:
( 5Sf) ,;;--.:; 7-L.,r/0 ,:::1
Type of Service to be Provided: f.tl Work Experience ~~ Community Service
/
Worksite location
Address:
City: Phone Number: s: ~ c;· ,;.7 3 7 -· L./f (; .;;-.
Extension:
Job Title: Duties to be Performed:
Minimum Requirements for the Position:
-/
Length of Project:
Weekly Hours Available (Maximum 40 hours/week): Special Clothing I Equipment Requirements:
6 .-
Worksite SupervF·sor Si n!____. tu. re.:
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