HomeMy WebLinkAbout20120448.tiff RESOLUTION
RE: APPROVE APPLICATION FOR COLORADO EMTS PROVIDER GRANT AND
AUTHORIZE CHAIR TO SIGN
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS, the Board has been presented with an Application for the Colorado EMTS
Provider Grant from the County of Weld, State of Colorado, by and through the Board of County
Commissioners of Weld County, on behalf of the Paramedic Service,to the Colorado Department of
Public Health and Environment, commencing upon full execution,with further terms and conditions
being as stated in said application, and
WHEREAS, after review, the Board deems it advisable to approve said application,a copy of
which is attached hereto and incorporated herein by reference.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld
County, Colorado, that the Application for the Colorado EMTS Provider Grant from the County of
Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on
behalf of the Paramedic Service,to the Colorado Department of Public Health and Environment be,
and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to
sign said application.
The above and foregoing Resolution was, on motion duly made and seconded, adopted by
the following vote on the 15th day of February, A.D., 2012.
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, COLORADO
ATTEST: ``\
Sean P. ay, Chair r_/
Weld County Clerk to the Board 3 6,17
I EL`«' illiam . Garcia, Pro-Tern
BY:
Deputy CI rk to the Boar am I t % - CUSED
•�ara Kirkmeyer
ApPROV AA ORM: O 171 WL
' cA,AA
�� ', David E. Lo
/County Attorney 1� 4QC )
Dougls Radem cher
Date of signature: 3-1`-/-/Q
d✓lo IUvC Ann
a-lu-I a 2012-0448
AM0021
1 8 6 I - 2 0 I I Weld County Paramedic Services
1121 M Street Greeley CO 80631
970-353-5700 Extension 3211
FAX: (970) 304-6408
W E L DEC O U N T Y dbressler(alco.weld.co.us
www.co.weld.co.us
February 9, 2012
Board of County Commissioners
Attached is the yearly State EMS Grant application for the purchase of one (1) ambulance as
approved in the 2012 Budget by the Commissioners. I have spoken with Commissioner Long and
would request the Board's approval.
Commissioner Approve Work Session Required
Conway �a
Kirkmeyer f
Garcia IA.c
Long Y J
Rademacher
Thank you,
Dave Bressler,
Director
2012-0448
Colorado EMTS Provider Grant Page 1 of 9
Colorado EMTS Provider Grant Request
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Weld County Paramedic Services (322) Date submitted: In Progress
Agency Information
1. Legal Name of Agency: Weld County Paramedic Services
2. Business Name: Weld County Paramedic Services
3. Federal Tax ID: 84-6000813
4. Grant Contact: DAVID BRESSLER
DIRECTOR
5. Agency Mailing Address: 1121 M St
Greeley, CO 80631
6. Primary Phone Number: 970-353-5700
7. Fax: 970-304-6408
8. E-Mail: dbressler@co.weld.co.us
9. Completed by: DAVID W BRESSLER
Grant Options
1. Organization Match Percentage: 500/0
2. Is this a multi-organizational Application? No
3. Select the counties that this grant project impacts: Weld
4. Please describe your overall grant request in ten sentences or less:
A 2012 Chevy G4500 Life Line Emergency Vehicles Superliner Ambulance.
Categories Selected
Category Total Price Match Agency Amount State Amount Amount Funded
Ambulance and Other Vehicles $158,830.00 50% $79,415.00 $79,415.00
Total for All Categories $158,830.00 79,415.00 $79,415.00
Ambulance and Other Vehicles Category Request
Items Requested:
Quantity Description Price Each Total Price Percent Agency State Amount
Match Amount Amount Funded
1 2012 Chevy G4500 Life Line $158,830.00 $158,830.00 50% $79,415.00 $79,415.00
Ambulance
Ambulance and other $158,830.00 $79,415.00 $79,415.00
Vehicles Category Total
Service Needs: t' v/,/
!J/o��vy$
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1. Briefly explain what type of vehicle you are requesting and why this vehicle is needed:
Weld County Paramedic Services has shortened the life cycle of the ambualnce. Replacement of ambulances is
now on a four (4) year life cycle. Miles, hours and cost per mile are evaluated by the Management Team in
coordination with the Weld County Controller/ Fleet Manager. The private vendor provides oversight and
record keeping of all maintenance and repair costs for budgetary review prior to to a recommendation on
which vehciles are retired and replaced.
2. Is this vehicle a replacement or an addition to your current fleet?
Vehicle replacment of a unit completing six (6) years of service.
3. If this vehicle is a replacement, enter the number of days the unit to be replaced was out of service for repairs
and explain what will be done with the old unit (sold, traded, donated, retired)?
0 - The old unit is still in service, completing it six (6) years of service and 170,000 miles.
4. What is the average length of service of vehicles operated, in miles or years?
4 - 5 years or 200,000 miles.
5. Briefly describe your vehicle replacement program:
Vehicles are replaced on a four (4) basis as they approach 200,000 miles of service. Historically Weld County
Paramedic Services had an active rechassis program, until problems were identified with a particular chassis
make and type. A program was initiated with the Board of County Commissioners approval to aggressively
switch to another make of chassis due to the unreliable performance and increased per/ mile costs. Critical
failure of units and excessive downtime created this need.
6. Describe your front line and back up rotations:
Cars are rotated between the 12 hour day and night shifts along with the one 24 hour shift in Ft. Lupton. Cars
are scheduled for preventative maintenance that is provided by a vendor under county contract.
7. Describe local support for this project and how this support will help ensure successful completion:
Support from the local chassis dealers that provide warranty work along with the ambulance dealer in the
Denver provide for a realiable, high quality unit emphasising safety and performance for the crews and
customer who rely on them during emergencies. The dealers and ambulance vendors have a committed
history of excellent service demonstrated in the state of the art fleet that Weld County Paramedic Servivces
relies on.
Priority to Underdeveloped or Aged Systems:
8. Explain how this proposed project addresses an underdeveloped or aged component of Colorado's EMS and
trauma system:
Providing a new resource in a system that covers close to 4,000 square miles of geography in all types of road
and weather conditions. Currently there are 12 ambulances in the fleet with a maximum deployment being
realized on busy days and increase call volume.
Cost Effectiveness:
9. Briefly describe the alternatives your agency considered and why this is the most cost effective alternative:
Rechassis was considered, in this case purchase of a new vehicle is desirable to eliminate a less realiable
brand of chassis and model as describe previously.
10. Briefly describe the process used to select the vehicle vendor:
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Weld County developed ambulance specifications and submitted an RFP. The vendor that was selected has
either met or exceeded all requirements in the bid process. Along with this the vendor has provided service
meeting the expectations of Weld County Paramedic Services.
11. How will this project be sustained financially in future years?
Weld County Government requires a flat line depreciation schedule matching the expected life cycle of the
ambulance for future replacment.
Applicants qualifications:
12. Explain how adequate resources and experience are available to help ensure successful completion of this
project:
Weld County has demonstrated a committment to quality and timely completion of all grant supported projects
that we have partnered with the State of Colorado EMS Division over the years of partnership. Weld County
commits the necessary resources internally and through our long standing relationship with vendors in the
ocmmunity to complete projects and demonstrated a positive impact on the provision of service to the citizens
and visitors of Weld County.
13. Explain how the applicant's qualifications will help ensure long term sustainability of this project:
Weld County commits to long term sustainability as demonstrated in the absence of debt in the county budget.
There is strong sense of committment and pride in monitoring how this resourece is managed when added to
the EMS System.
Systems Integration:
14. How does this project improve system compatibility and/or reduce duplication?
Weld County Paramedic Services relies on the tiered first response of the volunteer fire community in Weld
County. Firefighters and first responders often drive and ride-along in the back of the ambulances. Consistency
in the fleet helps tremendously as we train these agencies in vehicle operations.
Financial Need:
15. Explain why your organization needs grant funding to complete this project:
Weld County Paramedic Services operates as a fee for service enterprise of Weld County Goverment.
Diminshing revenues and collection rates along wtih the number of non-transport calls for service have had a
continued negative impact on the budget.
16. What would happen if these grant funds were not secured?
Funding alternatives would be pursued by the department, including consideration of level of match could be
secured via county and department funds.
File Attachments
17. Uploads - vendor quote required, letters of support Lifeline - 2012 Weld County Line item.pdf
recommended: Lifeline - 3029-31 Greeley, CO.pdf
Weld Cnty Safety Items pricing.pdf
Weld County Pricing 2012.pdf
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Organization Profile for Weld County Paramedic Services
Organization Data
A. Agency / Facility Information
1. Legal Name of Organization: Weld County Paramedic Services
ID Number: 322
Profile Year: 2012
Submission Date: 1/24/2012
2. Doing Business Name of Weld County Paramedic Services
Organization:
3. Physical Address: 1121 M St
Greeley, CO 80631
Physical County: Weld
4. Mailing Address: 1121 M St
Greeley, CO 80631
5. Person Filling out this Profile: DAVID W BRESSLER
Title: DIRECTOR
6. Primary Phone Number: 970-353-5700 ext 3211
7. Fax Phone: 970-304-6408
8. E-Mail: dbressler@co.weld.co.us
9. Web Site: www.co.weld.co.us/departments/paramedic_services/ambulance.html
10. RETAC Affiliated With: Northeast Colorado
B. Organization Types
1. EMS Response: Yes
2. Medical Facility: No
3. EMS Education Program: No
4. County officials issuing ambulance No
licenses or County EMS Councils:
5 RETAC: No
6. Association / Foundation / Other: No
C. Service Area
1. In one or two short paragraphs Weld County Paramedic Services is the primary advanced life support
describe the geographic area licensed transport agency in Weld County Colorado except in the
serviced by this organization: following areas. Frederick Firestone and Mountain View Fire
Departments provide ambulance coverage is their fire districts, along
with Platte Valley EMS from Brighton Colorado responding north to
Weld County Road 6 with the Greater Brighton Fire District.
D. Funding
1. Is this organization interested in Yes
EMTS Section funding programs?
EMS Contacts
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A. EMS Organization
1. EMS Organization Name: Weld County Paramedic Services
2. Licensing:
Is this organization a county licensed Yes
ground ambulance service?
Is this organization a Colorado licensed No
air ambulance service or currently
applying for licensure?
B. EMS Service Director
1. Director's Name: David Bressler
Job Title: Director
2. Mailing Address: 1121 M St
Greeley, CO 80631
3. Primary Phone Number: 970-353-5700 ext. 3211
4. E-Mail: dbressler@co.weld.co.us
C. EMS Alternate Contact
1. Alternate Contact's Name: Mitch Wagy
Job Title: Medical Operations Manager
2. E-Mail: mwagy@co.weld.co.us
D. EMS Medical Director
1. Medical Director's Name: Benji Kitagawa
2. Mailing Address: 1121 M St
Greeley, CO 80631
3. Primary Phone Number: 970-353-5700 ext. 3211
4. E-Mail: bkitagawa@co.weld.co.us
5. Colorado Medical License Number: 30531
E. EMS Data Administrator
1. EMS Data Administrator Name: DAVID GOSS
Job Title: IT SUPPORT
2 Primary Phone Number: 970-356-4000 ext. 2546
3. E-Mail: dgoss@co.weld.co.us
F. Emergency 24 Hour Contact
1. Emergency Contact Name: DAVID BRESSLER
Job Title: DIRECTOR
2. Primary Phone Number: 970-302-1127
3. E-Mail: dbressler@co.weld.co.us
Services and Structure
1. Organizational Structure: 3rd Service (governmental
2. Corporate / Tax Status: government
3 Government Type: County
3a. Is this EMS service established as a Yes
governmental enterprise or enterprise
fund?
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3b. Indicate the Type of Special District for N/A
this EMS Service:
4. Funding Types: User Fees,
grant
5. Billing Method: In-house
6. Primary service provided by your EMS Scene response with transport
Organization:
7. Other services provided by your EMS Scene response without transport,
organization: Interfacility transport,
Convalescent medical transport
8. What level of provider can your service Paramedic
send to EVERY call?
Personnel
Category Full Time Part Time Volunteer Total
1. First Responder
2. Emergency Medical Technician (EMT): 14 12 26
3. Advanced Emergency Medical
Technician (AEMT):
4. Intermediate 2 2
5. Paramedic 31 24 55
6. Nurse
7. Physician
8. Administrative / Other 5 5
9. Full-Time Equivalent Count: 50
Requests for EMS Services
A. Requests for Services
1. Emergency Response with Transport: 9,698
2. Interfacility Transports: 1,474
3. Emergency Response, no Transport: 1,692
4. Emergency Response Care Transferred / 2,565
Transport by Other:
5. Standby: 140
6. Cancelled Calls: 1,234
7. Total: 16,803
B. EMS Financial Resources
1. Total Annual EMS Budget for this $5,646,856.00
Organization:
2. Total Annual EMS Charges Billed: $17,652,675.00
3. Total Annual EMS Charges Collected: $5,646,856.00
4. Crude Collection Rate: 31.99%
Counties Licensed In
1. List all counties where this agency is Weld
licensed for Ground transport services:
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Vehicles
Unit Make / Model / Year Box Make Mileage Equipped All Wheel Type Bought Replacement
Number For Drive kkk.1822 with EMS Year
Funds
11- Ford / E350 / 2004 US Bus 6,099 BLS Other 2015
MiniBus
222- FORD / Expedition / 2005 Ford 141,258 BLS Other 2012
EMSCom
31 Ford / E-350 / 2006 Braun 151,885 ALS III 2010
32- Ford / E350 / 2006 Ford 195,100 BLS Other 2012
EMS1 Va
37 Chevy / G4500 / 2009 Braun 85,446 ALS III Yes 2013
38 Chevy / G4500 / 2009 Braun 59,748 ALS III Yes 2013
39 Chevy / G4500 / 2009 Lifeline 59,972 ALS III 2014
40 Chevy / G4500 / 2009 Lifeline 56,837 ALS III 2014
41 Chevy / G4500 / 2009 Lifeline 61,266 ALS III 2014
42 Chevy / G4500 / 2009 Lifeline 65,554 ALS III 2015
43 Chevy / G4500 / 2009 Braun 41,726 ALS III Yes 2015
44 Chevy / G4500 / 2010 Lifeline 18,553 ALS III 2015
45 Chevy / G4500 / 2010 Lifeline 20,599 ALS III 2015
46 Chevy / G4500 / 2010 Lifeline 23,225 ALS III 2015
47 Chevy / G4500 / 2011 Lifeline 8,037 ALS III Yes 2016
EMS Ground Demographics
A. Demographics of Service Area for Ground Transport
1. Population Density / Urbanicity: Suburban
2. Employment Type: Paid
3. Number of stations for this Service: 4
4. Average Call Time (Dispatch to Back-In- 25.00 minutes
Service:):
5. Average patient mileage per transport: 16.00 miles
6. Total square miles of your primary 3,992
service area (land & water):
7. Estimated permanent population of your 252,825
primary service area:
8. Population Density of Service Area: 63.33
B. System Participation
1. Is your agency National Incident Yes
Management System (NIMS) compliant?
C. EMS Ground Billing Rates
•
1. BLS Emergency - HCPCS Code A0429: $1,597.00
2. ALS Emergency - HCPCS Code A0427: $1,812.00
3. ALS Level 2 - HCPCS Code A0433: $2,295.00
4. Specialty Care Transport - HCPCS Code $0.00
A0434:
5. Mileage Rate - HCPCS Code A0425: $20.00
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Funding Information
1. Legal Name of Organization: Weld County Paramedic Services
2. Tax ID Number: 84-6000813
Grant Management Contact
1. Grant Management Contact Name: DAVID BRESSLER
Job Title: DIRECTOR
2. Mailing Address: 1121 M St
Greeley, CO 80631
3. Primary Phone Number: 970-353-5700
4. E-Mail: dbressler@co.weld.co.us
Authorized Official
1. Name of Authorized Official able to sign Sean Conway
contracts:
Job Title: Chairman Weld County Board of Commissioners
2. Is the Authorized Official the chair or Yes
president of the governing board for this
organization?
Financial Narratives
1. Briefly Describe how this organization is Weld County Paramedic Services is an enterprise of Weld
funded and why it may require EMTS County Goverment. As such it receives no taz funds from
grants: Weld County, instead being a fee for service agency. An
increasing demographic of Medicaid, Medicare and
indigent popultation, result in diminishing collection rates.
2. Briefly describe any affiliations or Weld County Government operates the Weld County
partnerships this organization has with Regional Communications Center, Weld County Health
any parent or subsidiary organizations: Department and Weld County Human Services. Weld
County Paramedic Services is a member of Northeast
RETAC, Northeast Physician Advisory Board (NEPAB) and
Weld County EMTS Council. Our Medical Director is also
the Regional Medical Director for the NEPAB, a member of
the EMPAC and an affilate member of the North Colorado
Health Alliance.
3. File attachments: 20]3 Financials.pdf
Past Years Grant History
Year Category Total Requested State Amount Funded Amount Spent
2012 Ambulance and Other Vehicles $154,215.00 $138,793.50 $138,794.00 $0.00
2011 EMS and Trauma Equipment $105,525.00 $79,143.75 $79,144.00 $13,799.56
2010A EMS and Trauma Equipment $8,780.00 $4,390.00 $4,390.00 $4,398.76
2010A Ambulance and Other Vehicles $99,500.00 $49,750.00 $49,750.00 $46,777.50
2010 Ambulance and Other Vehicles $93,500.00 $46,750.00 $46,750.00 $46,350.00
2009 Ambulance and Other Vehicles $76,800.00 $38,400.00 $38,400.00 $38,400.00
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Additional Attachments
1. W-9, Vendor Disclosure and Attestation: No files found
Close
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Provider Grant Attestation
Dose
1. Legal Name of Agency: Weld County Paramedic Services
2. DBA (Doing Business As - If Applicable: Weld County Paramedic Services
3. Federal Tax ID Number: 84-6000813
4. Grant Contact Person: DAVID BRESSLER
DIRECTOR
Authorized Agent
The individual whose name and signature appear below, has been designated by the agency/organization listed
above as the Authorized Agent to complete and submit this grant application on its behalf. The agency/organization
agrees to comply with the rules and regulations governing the State of Colorado EMTS Grants Program concerning
grant requests.
Financial Information
5 The Authorized Agent attests to the agency or organization's ability to provide the matching funds (50%, 40%,
30%, 20% or 100/0) to complete the purchase of the grant award, should the agency be awarded state funds.
6 The Authorized Agent is aware that EMTS vehicles and equipment purchased must be without any financial
liens and without the item being used as collateral to secure a loan of any kind.
The Authorized Agent attests that, to the best of his/her knowledge, the information contained herein, with
7. regard to the Agency's financial condition, is true, accurate and correctly reflects the financial condition of the
agency/organization.
Notification of Affected Entities
By signing below, the Authorized Agent also attests to the fact that:
The agency(ies)/organization(s) affected by the possible outcome of this grant request, including but not
8. limited to agencies/organizations listed in this application if it is a multi-agency application, has(have) been
notified and has(have) agreed to its submission.
Applicant Duties and Obligations Should Funding be Awarded
Should the agency/organization listed in this application receive funding under this grant application, the
agency/organization (hereinafter referred to as "grantee") shall, and affirmatively promises to, comply with all of
the provisions set forth below.
9 The grantee shall use grant funds received under this grant to complete all aspects of its grant application,
and shall not use such funds for purposes other than this.
10. The grantee shall submit quarterly progress reports to the Colorado Department of Public Health and
Environment, EMTS Category (hereinafter referred to as 'the State').
11. Requirements for Training and Education Grants
For any training or education requests funded from this application the grantee shall comply with the following
terms and conditions:
Reimbursement for all travel expenses associated with the training or education program shall be made
A. in accordance with the then current state of Colorado reimbursement rates for travel as specified in the
Fiscal Rules of the state of Colorado.
Written proof of the successful completion of any training or educational program shall be submitted at
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B. the same time as the invoice requesting reimbursement for that training or educational program.
C. Prompt billing at the end of each quarter or semester is expected.
If the grantee provides a training or educational program, then the grantee shall acknowledge the use of
D emergency medical and trauma services account grant funds in all public service announcements,
program announcements, or any other printed material used for the purpose of promoting or advertising
the training or educational program.
If the grantee provides a training or educational program, then the grantee shall develop and utilize a
E course evaluation tool to measure the effectiveness of that training or educational program. The grantee
shall submit a copy of all evaluation reports to the State upon completion of the training or educational
program.
12. Requirements for Equipment Grants
For any equipment purchases funded from this application, the grantee shall comply with the following
requirements.
A The grantee shall provide the state with written documentation of the purchase of the specified
equipment.
All communications equipment shall be purchased from the State award for communications equipment,
or from another vendor for a comparable price and quality. If the grantee desires to purchase
B communications equipment which is not listed on the State award then the grantee must complete, with
the State's assistance if needed, an informal competitive solicitation process before purchasing that
equipment. If a competitive solicitation process is used, then the grantee shall purchase the
communications equipment from the lowest bidder whose bid meets the bid specifications.
If the grantee desires to purchase emergency vehicles other than ambulances, then the grantee must
complete, with the State's assistance if needed, an informal competitive solicitation process before
C purchasing that equipment. The proposed specifications for these emergency vehicles must be approved
by the State prior to the initiation of the informal competitive solicitation process. If a competitive
solicitation process is used, then the grantee shall purchase the emergency vehicles from the lowest
bidder whose bid meets the bid specifications.
If the grantee desires to purchase medical equipment, then the grantee must complete, with the State's
D assistance if needed, an informal competitive solicitation process before purchasing that equipment. If a
competitive solicitation process is used, then the grantee shall purchase the medical equipment from the
lowest bidder whose bid meets the bid specifications.
During the initial term and any renewal or extension term of the contract or purchase order issued to
convey funding to the grantee, and after the cancellation, termination, or expiration date of said contract
E. or purchase order, the grantee shall acquire and maintain personal property casualty insurance for the
replacement value of all equipment it purchases under this grant for the useful life of that purchased
equipment.
The grantee shall keep inventory control records for all equipment it purchases. The grantee shall obtain
F. the prior, express, written consent of the State before relocating or reallocating any equipment it
purchases.
The grantee shall provide the State with a picture of each piece of equipment it purchases. The grantee
G. may submit a picture of a piece of purchased equipment at any time, but in no event no later than the
date the grantee's final progress report is due to the State.
The grantee shall maintain all equipment it purchases in good working order, normal wear and tear
excepted. The grantee shall perform all necessary maintenance services for all equipment it purchases in
H. a timely manner and in accordance with all manufacturer's specifications and all manufacturer's warranty
requirements. The grantee shall keep detailed and accurate records of all maintenance services it
performs on all equipment it purchases.
I The grantee shall repair or replace all purchased equipment which is damaged, destroyed, lost, stolen, or
involved in any other form of casualty.
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If the grantee ceases to provide emergency medical and trauma services in the state of Colorado, then
all equipment purchased under this grant shall either be placed with another operating emergency
medical services provider in the state of Colorado, or be sold at public auction for its then fair market
J.
value. That portion of the sale proceeds which equals the State's initial financial contribution towards the
purchase of that equipment shall be refunded to the State by the grantee. The grantee shall obtain the
prior, express written consent of the State prior to any relocation or sale of any purchased equipment.
Authorized Agent
13. Name Sean Conway
14. Title Chairman Weld County Board of Commissioners
15. Daytime Phone Number 970-353-5700
16. Date FEB 1 5 2012
17. Signature of Authorized Agent
1.44 2
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VENDOR DISCLOSURE STATEMENT
Contract Performance Outside the United States or Colorado
Colorado Revised Statute 24-102-206
Contract or Purchase Order Routing Number:
Vendor Name:
The person completing this form should be the business' President, Board Chairperson,
Contract's Authorized Signatory or the Purchase Order's Statement of Work Signatory.
This form shall be completed and returned to the contracting agency. This applies to all state
contracts and purchase orders for services executed after August 3, 2007.
1. Are any services under the contract or any subcontracts or purchase order anticipated to be
performed outside the United States or Colorado?
Yes Ti No ❑
If"Yes",please complete the following two questions and then sign the form.
If"No",please sign the form.
2. Where will the services be performed under the contract,including any subcontracts or
purchase order? (List country(ies) and/or state(s).
3. Explain why it is necessary or advantageous to go outside of the United States or the State of
Colorado to perform the services under the contract or any subcontracts or purchase order.
Signature: < 41:12Printed Name Sean P. Conway
Title: Chair, Weld Count Board Date: FEB 1 5 2012
of Commissioners
CDPHE VDS Form Page 1 of 1 Created November 8,2007
020/07-OW8
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