Agency Nepotism Certification

AGENCY CERTIFICATION

In submitting this proposal to CSC ______certifies that: (Agency Name)

  1. The applicant agency qualifies to submit a proposal under the provisions in the RFP Minimum Requirements;
  1. The date that this proposal was or will be approved by the agency board of directors was/is ______.
  1. All agency decisions regarding recruitment, hiring, promotions, release, and conditions of employment will be made without regard to consideration of race, creed, religion, gender, country of national origin, age, physical or mental handicap, marital status or any other factor which cannot lawfully be used as a basis for an employment decision;
  1. The agency agrees to negotiate, if deemed necessary, with CSC to refine service levels, procedures, objectives, budget, and any other relevant matter for incorporation into a contract;
  1. The applicant agency does not intend by this proposal to replace existing funding resources with CSC funds;
  1. The budget included in this proposal is a reasonable estimate of the anticipated revenues and expenditures for the activities proposed;
  1. A copy of the current IRS 501(c)(3),(4),(6),(7), or (10) Certificate (for not-for profit agencies) is included with the submission of this proposal;
  1. Any of the following documents are available and upon request by CSC will be produced by the applicant agency within five (5) working days, but do not need to be submitted with this proposal:

a)  Articles of Incorporation

b)  Personnel Policies and Procedures

c)  Job Descriptions

d)  Certificates of Insurance and Bonding

e)  Licenses to Operate Agency/Program

  1. NO litigation is threatened or pending which could impair the applicant agency's ability to fulfill the provisions of this proposal.
  1. NO adverse action is pending or threatened by any regulatory, licensing, or oversight agency which could impair the applicant agency's ability to fulfill the provisions of this proposal.

If any of the above documents are not available or any of these statements cannot be made, please explain below:

OFFICIAL AUTHORIZED TO SIGN AND BIND AGENCY TO PROPOSAL (Authorized officials recognized by CSC are the Board Chair or President and Executive Director.)

Name of Agency/Program

______

Board Chair Signature

______Date:______

Print Name

______

Executive Director Signature

______Date:______

Print Name

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