2011 Request For Proposal Cover Sheet Template Page 5
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11STATE OF CONNECTICUT, Department of Public Health RFP # 2011-0917; Tobacco Use Cessation Services
APPLICATION FORMS
Subcontractor Schedule B-Detail
#1
Program:
Subcontractor Name:
Address:
Telephone: (
) (
-
)
Select One:
A
Budget Basis
B
Fee-for-Service
C
Hourly Rate
Indicate One:
MBE
WBE
Neither
Line Item
Amount
Total Subcontract Amount:
#2
Subcontractor Name:
Address:
Telephone: (
) (
-
)
Select One:
A
Budget Basis
B
Fee-for-Service
C
Hourly Rate
Indicate One:
MBE
WBE
Neither
Line Item
Amount
Total Subcontract Amount:
#3
Subcontractor Name:
Address:
Telephone: (
) (
-
)
Select One:
A
Budget Basis
B
Fee-for-Service
C
Hourly Rate
Indicate One:
MBE
WBE
Neither
Line Item
Amount
Total Subcontract Amount:
(Attach resumes for all Professional Staff)
RFP # 2011-0917 APPLICATION FORMS
Page 5 of 11
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