Attachment A-3



Form A-3Contractor Service InformationService Delivery Staff QualificationsEach direct service provider must meet the Minimum Qualifications described in Provider Enrollment (PEN) §2.6. Form PCS-102SUD, Contracting Entity and List of Staff, Subcontractors, and Volunteers, must be completed for each person who will provide services under any contract award pursuant to this PEN. This completed form must be submitted with the Application and is available in Package 3 on the main page of this Enrollment. This form is also available at: you have indicated the use of subcontractors on PCS-102SUD, the following must be submitted for review:Subcontracting policies and procedures and a copy of the subcontract to be used in the delivery of services being contracted and that are in compliance with procurement, monitoring and processing back ground check requirements. DFPS will utilize the Subcontracting Review & Acceptance Form, PCS-107 to document acceptance of these policies and procedures and the subcontract document. The Contractor is encouraged to use Form PCS-107: located at: Service Delivery Area DetailApplicant selected the Region(s) to serve in the PEN Document §8.3, Form 2280PEN Application and Contract, Number 5. DFPS Regions are served on a region wide basis. Actual service delivery location(s) are based on requirements and restrictions of DSHS license.OfficesPrimary OfficeApplicant’s primary office is designated on Form 2280PEN, Application and Contract, #3, Contact Information. Complete the table below, providing a schedule for the days and times routinely available to provide services at the primary office location. These represent only routine days and times. Applicant will be expected to adjust schedule to accommodate the needs of DFPS clients.DAYHOURSFromToFromToExample7 AMNoon2 PM7 PM FORMCHECKBOX Monday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Tuesday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Wednesday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Thursday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Friday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Saturday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Sunday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Will you, your staff, or subcontractors be delivering services from satellite office sites other than the location listed on Form 2280PEN, Application and Contract, #3? FORMCHECKBOX Yes - (if yes, be sure to complete question 4.4 below) FORMCHECKBOX NoSatellite Office(s)Designate any satellite office(s) by completing the table and providing a schedule indicating days and times routinely available to provide services at each satellite office location. These represent only routine days and times. Applicant is expected to adjust schedule to accommodate the needs of DFPS clients. Use additional copies of this section, as necessary, to provide complete information.Service Delivery Address FORMTEXT ?????City, State, Zip FORMTEXT ?????Phone FORMTEXT ?????Fax FORMTEXT ?????Contact Person FORMTEXT ?????E-mail FORMTEXT ?????DAYHOURSFromToFromToExample7 AMNoon2 PM7 PM FORMCHECKBOX Monday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Tuesday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Wednesday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Thursday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Friday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Saturday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Sunday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Service Delivery Address FORMTEXT ?????City, State, Zip FORMTEXT ?????Phone FORMTEXT ?????Fax FORMTEXT ?????Contact Person FORMTEXT ?????E-mail FORMTEXT ?????DAYHOURSFromToFromTo FORMCHECKBOX Monday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Tuesday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Wednesday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Thursday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Friday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Saturday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Sunday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? ................
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