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Request for Qualifications <br />Employment and Day Program Services <br /> <br /> <br />2017 Kittitas County RFQ 13 <br />Attachment A <br /> <br />Cover Sheet <br /> <br />General Information: <br /> <br />Select the Employment and Day Program Services Your Agency Seeks to Provide: <br /> <br /> Community Access <br /> <br /> Individual Supported Employment / Group Supported Employment <br /> <br /> <br /> <br />Legal Name of Applicant Agency <br /> <br />Mailing Address <br /> <br />City County State Zip <br /> <br />Contact Person Title <br /> <br />Phone Fax <br /> <br />Email address <br /> <br />Program Location (if different than above) <br /> <br />Tax Identification Number <br /> <br /> <br />I certify that to the best of my knowledge the information contained in this Submission of Qualifications <br />is accurate and complete and that I have the legal authority to commit this business or agency to a <br />contractual agreement. I realize the final funding for any service is based upon funding levels and the <br />approval of County officials. <br /> <br /> <br /> <br /> <br /> <br />Signature and Title Date