Disability Services Division (DSD)
Provider Network

2008 – APPLICATION

General Information

Section A:
National Provider Identifier (NPI) Number  				
Federal Employers Tax ID (FEIN) Number: 				
Agency Name _______________________________________________
Medicare certified   Yes___ No ___	Medicaid Certified   Yes ___ No ___  
Service Location MA # (if applicable):				   Site # (if applicable)______________
Service Location Name: 							  
Business Address: 
City:  							State:			Zip:
Business Telephone (     )	Fax (     )

Mailing Address if different from above:
Address:  
City:  							State:			Zip:	
Website Address (if available):  http://www.						
 (NOTE: 	Agencies are required to have an E-mail Address. Please print legibly or type e-mail address in the space provided.)

Agency Director  	Director Telephone (     )			
Agency Contact 	Contact Telephone (     )	
Agency/Contact E-Mail Address:  

Wheelchair Access	  Yes	  No
Handicapped Parking	  Yes	  No
DD/TTY Number	  Yes	  No (If yes, phone number: 			) 

Section B:
If your agency is a subsidiary of another agency (the parent), please identify it below:  
Parent Agency:  			                            Parent Agency Telephone  (     ) 		
Parent Agency Address:  
City:  		State:			Zip:	 		
Parent Agency Contact:				 Parent Agency Contact Telephone  (     ) 		

Additional Locations

If your agency has additional sites that will be utilized to provide services through DSD or the Care Management Organization (CMO), please complete an additional Page 1 (Section A only) of this application for each site:  Please attach an agency license for each site, if applicable.

	Agency Information	

Please check all the statements below that best describes your business operation: 
  Individual Credentialed Provider	  Partnership				  For Profit Agency   
  Service Corporation 			  Corporation				 Non-Profit Agency
  Sole Proprietorship 			  Limited Liability Corporation (LLC)  	 Single Member LLC

Is the Agency Incorporated?     Yes     No (If yes, please enclose articles of incorporation)
Is the Agency a LLC? 	            Yes    No (If yes, please enclose articles of organization and operating  
                                                                                   agreement)
Please check all that apply:
Population served:  Developmentally Disabled  Physically Disabled   Mental Health 
  Autism 	 Frail Elderly	      AODA        TBI       Alzheimer’s      Other 		______
Days/Office Hours: 											

MINORITY OR DISADVANTAGED VENDOR	
  Yes	  No    (If yes - Check all that apply)

Minority Vendor					Disadvantaged Vendor
 	At least 51% of the Board		At least 51% of the Board of
	Directors are minorities		Directors are women
	Organization is owned and		Organization is owned and
	operated by at least 51% minorities		operated by at least 51% women

FAITH-BASED ORGANIZATION:	  Yes	   No
(defined as affiliation with a denomination or church)

BI-LINGUAL STAFF AVAILABILITY
Is any of your staff bi-lingual?   Yes   No   If yes, Language(s) Spoken: ____________________

SIGN LANGUAGE
Do any of your service providers work with deaf or hearing-impaired clients?   Yes   No

Individual Providers Currently Working for an Agency in the DSD or  CMO/Family Care Program Applying to Join the Network as a New Agency or Sole Provider 

Sole Providers (individuals in the DSD or CMO who are one-person agencies) may not simultaneously provide the same services for other agencies in the DSD or CMO without first informing that Agency’s Director, in writing a notification letter, of their intent to do so.  A copy of the notification letter must be submitted with the application.  Complete the following as applicable:

1.	List agencies in the Network that you are employed by or affiliated with (e.g., consultant, Board of Directors, or in an executive/managerial role).

2.	List Milwaukee County programs for which you are currently providing services (Wraparound Milwaukee, WIser Choice, Disabilities Services Division, Department on Aging, Children’s Court Center, etc.).  																																															

References

Please be advised that DSD or the CMO may require start-up agencies or agencies in business for less than five years to submit two letters of reference to follow a format prescribed by DSD or the CMO.  

REQUIRED DISCLOSURES

1.		Has your company or any representative, owner, partner or officer ever failed to perform work awarded or had a contract terminated for failure to perform or for providing unsatisfactory service?

  Yes    No	If yes, on a separate page please provide a detailed explanation.

2.	Within the past five (5) years, has your company or any representative, owner, partner or officer (collectively “your company) ever been a party to any court or administrative proceedings where the violation of any local, state or federal statute, ordinance rule or regulation by your Company was alleged?  

  Yes    No		If yes, on a separate page, please provide a detailed explanation outlining the     
		following:
•	Date of citation or violation
•	Description of violation 
•	Parties involved
•	Current status of citation

3.	Within the past 5 years has your organization had any reported findings on an annual independent audit? 

  Yes    No	  If yes, on a separate page please provide a detailed explanation.

4.	Within the past 5 years, has your organization been required to submit a corrective action plan by virtue of review or audit by independent auditor, or any governmental agency or purchaser of services?  
	
  Yes    No	  If yes, on a separate page please provide a detailed explanation including if the   
 	corrective action has been accepted by the purchasing agency and completely implemented?  If not, please explain remaining action required by purchasing agency.

5.	Have you, any principals, owners, partners, shareholders, directors, members or officers of your business entity ever been convicted of, or pleaded guilty, or no contest to, a felony, serious or gross misdemeanor, or any crime or municipal violation, involving dishonesty, assault, sexual misconduct or abuse, or abuse of controlled substances or alcohol, or are charges pending against you or any of the above persons for any such crimes by information, indictment or otherwise?  

	  Yes    No	  If yes, on a separate page, please provide a detailed explanation.

Experience/Service Proposal

Briefly address each question identified below. 	If a topic does not pertain to your type of business, please indicate N/A.  

For each service (see enclosed Exhibit A, List of Service Names and Descriptions) that you provide or are proposing to provide, how long have you been providing this service and for what type of population? (Insert corresponding number in Population code).  Use additional pages if necessary.
1 Developmentally Disabled (DD), 2 Physically Disabled (PD), 3 Autism, 4 Frail Elderly, 5 Mental Health, 6 Alzheimer’s, 7 AODA, 8 TBI, 9 Other Area

SPC #	Z
Code
If
Applicable	Service
Provided
i.e., AFH, Lawn Service	Population
Code	Ages Served	Current Provider to Milw Cnty DSD or CMO	Length of
Time Providing
Service
	
(A)	(B)	(C)	(D)	(E)**	(F)	(G)	

		 0-3   3-18   18-59   60 +  	 Y   N  		

		 0-3   3-18   18-59   60 +  	 Y   N  		

		 0-3   3-18   18-59   60 +  	 Y   N  		

		 0-3   3-18   18-59   60 +  	 Y   N  		

1.	What agencies/organizations have referred business to you over the past three years? 																																														

2.	List any agencies/organizations with whom you have had contractual relationships within the previous three years:  																																											

Service Capacity/Resources & Limitations

In the row that corresponds to the Service Code for the respective service on the prior page, please respond to the requested capacity information in the following table for services that you provide or are proposing to provide to Milwaukee County DSD or CMO consumers.  **Data is only required for the services identified in Exhibit A, List of Service Names and Descriptions (See enclosure for special instructions for certain products or services).  Use additional pages if necessary.

SPC #	DSD
Z
Code
If
applic	For each 
service, 
total
 no. of 
unduplicated consumers 
you are 
presently able 
to serve 
at any 
one time	For each 
service, 
total
no. of 
unduplicated consumers 
you are
 currently
 serving	For each service, 
total 
no. of unduplicated consumers 
you are proposing to 
add capacity
 for within 
next 
2 years	Names of other contracting counties, agencies or other organizations	Describe the Geographic Service Area (Milw Co, SE WI, State-wide, etc.) you are serving or are proposing to serve and any other limitations (e.g., resources, etc.) to providing this service	
(A)	(B)	(C)	(D)	(E)	(F)	(G)	

	

	

	

	

Documentation Required

1.	AGENCY LICENSE 
A copy of the agency license/s must be submitted with this application as issued to the agency by the State of Wisconsin or Milwaukee County corresponding to the service/s provided or for those services the agency is applying for, such as Adult Day Care, Group Home, Foster Care, Residential Licenses.  

2.	EQUAL EMPLOYMENT OPPORTUNITY CERTIFICATE and EQUAL OPPORTUNITY POLICY 
Agencies having a Milwaukee County contract and 50 or more employees shall develop and/or update an Affirmative Action Plan as outlined on page 11 of this application.  The Equal Opportunity Policy must also be completed and signed (page 12).  Plans and/or updates shall be submitted within 120 days of contract award to Audit Compliance Manager, Milwaukee County Department of Audit, 2711 West Wells Street, Ninth Floor, Milwaukee, WI  53208   [Phone No: (414) 278-4246]

Information regarding basic statistics on population and labor force may be obtained from the DWD website at www.dwd.state.wi.us/oea/oea_products.htm or by contacting, Labor Market Analyst, State Office Building, 201 East Washington Street, Madison, WI 53707, (608) 266-0851.  

3.	CIVIL RIGHTS COMPLIANCE PLAN
Agencies which have a Milwaukee County contract shall have a Civil Rights Compliance Action Plan which ensures that no person shall, on the grounds of race, color, national origin, age, sex, religion, or handicap, be excluded from participation in or be subjected to discrimination in any program or activity funded, in whole or in part, by Federal and State funds. 

Consistent with the requirements of the U.S. Department of Health and Human Services, the State of Wisconsin Department of Workforce Development (DWD) and the Department of Health and Family Services (DHFS), Contractor is required to complete and submit a copy of a Civil Rights Compliance Plan (CRCP) to include Affirmative Action, Equal Opportunity, and Limited English Proficiency (LEP) Plans, or Contractor may submit a copy of the State approval letter to County in lieu of the CRCP.  

Contractors with direct State contracts with DWD or DHFS with fewer than 25 employees, or Contractors receiving less than $25,000 in direct State funding are required to file a Letter of Assurance with DWD or the DHFS, and a copy with County.  Contractors with fewer than 25 employees or Contractors receiving less than $25,000 in funding or payment from County are required to file a Letter of Assurance with County.  Completion forms, instructions, sample policies and plans are posted on the State website at: www.dwd.state.wi.us/dws/civil_rights/cr0406/cr_plans.htm.  

Civil Right Plans or Letters of Assurance shall be submitted within 120 days of contract award to
 Milwaukee County Department of Health and Human Services
Contract Administrator 
1220 W. Vliet Street, Suite 109
Milwaukee, WI  53205

4.	INSURANCE COVERAGE
If awarded an agreement with DSD or Family Care, the agency is required to obtain insurance coverage as outlined on page 9 and 10 of this application.  Certificates of Insurance must be submitted to Milwaukee County DHHS Contract Administrator at above address.  

           Documentation Required – cont’d

5.	INDIVIDUAL SERVICE PROVIDER CREDENTIALS 
The agency is responsible to ensure that individual service providers maintain good standing during the term of this agreement.  This includes all required licenses and/or certifications as required by federal, state, and local laws and regulations required to the provision of services required under this agreement.  A copy of individual providers’ current licenses/certifications must be maintained at the agency and made available for review upon request.  

6.	CRIMINAL BACKGROUND CHECKS 
Criminal Background Checks (CBCs) are required for all employees who work with or may come into contact with members.  The background check must meet the standards set forth in the State of Wisconsin Caregiver Law, ss.50.065 and ss.146.40 Wis. Stats. and HFS 12 and HFS 13, Wis. Admin. Code State of Wisconsin Caregiver Program.  A copy of individual service provider CBCs must be maintained at the agency and made available for review upon request.

INSURANCE COVERAGE

Contractor agrees to evidence and maintain proof of financial responsibility to cover costs as may arise from claims of tort, statutes and benefits under Workers’ Compensation laws and/or vicarious liability arising from employees, board, or volunteers.  Such evidence shall include insurance coverage for Worker’s Compensation claims as required by the State of Wisconsin, Commercial General Liability and/or Business Owner’s Liability (which includes board, staff, and volunteers), Automobile Liability (if the Agency owns or leases any vehicles) and Professional Liability (where applicable) in the minimum amounts listed below.

Automobile insurance that meets the Minimum Limits as described in the Agreement is required for all agency vehicles (owned, non-owned, and/or hired).  In addition, if any employees of the Contractor will use their personal vehicles to transport Milwaukee County employees, representatives or clients, or for any other purpose related to the Agreement, those employees shall have Automobile Liability Insurance providing the same liability limits as required of the Contractor through any combination of employee Automobile Liability and employer Automobile or General Liability Insurance which in the aggregate provides liability coverage, while employee is acting as agent of employer, on the employee’s vehicle in the same amount as required of the Contractor.

If the services provided under the contract constitute professional services, Contractor shall maintain Professional Liability coverage as listed below. Treatment providers including psychiatrists, psychologists, social workers) who provide treatment off premises must obtain General Liability coverage (on premises liability and off-premise liability), to which Milwaukee County is added as an additional insured, unless not otherwise obtainable. 

It being further understood that failure to comply with insurance requirements might result in suspension or termination of the Agreement.
	
Type of Coverage:	Minimum Limits:
Wisconsin Workers’ Compensation	Statutory
or Proof of all States Coverage

Employers’ Liability	$100,000/$500,000/$100,000
	
Commercial General Liability
Bodily Injury & Property Damage	$1,000,000 - Per Occurrence
Incl. Personal Injury, Fire, Legal
Contractual & Products/Completed	$1,000,000 - General Aggregate
Operations)

Automobile Liability
Bodily Injury & Property Damage	$1,000,000 Per Accident
All Autos - Owned, Non-Owned
and/or Hired

Uninsured Motorists	Per Wisconsin Requirements

Professional Liability  	
To include Certified/Licensed Mental	$1,000,000 Per Occurrence
Health and AODA Clinics & Providers	$3,000,000 Annual Aggregate
And Hospital, Licensed Physician or 
any 		As required by State Statute

And Hospital, Licensed Physician or 
any other qualified healthcare provider	As required by State Statute
under Sect 655Wisconsin Patient 
Compensation Fund Statute		

INSURANCE COVERAGE – cont’d

Any non-qualified Provider under 				$1,000,000 Per Occurrence/Claim
Sec 655 Wisconsin Patient 					$3,000,000 Annual Aggregate
Compensation Fund Statute State
Of Wisconsin (indicate if Claims	
Made or Occurrence)

Other Licensed Professionals				 	$1,000,000 Per Occurrence
$2,000,000 Annual Aggregate, or
Statutory limits whichever is higher

Should the statutory minimum limits change, it is agreed the minimum limits stated herein shall automatically change as well.

The Milwaukee County Department Health and Human Services, as its interests may appear, shall be named as, and receive copies of, an “additional insured” endorsement, for general liability, automobile insurance, and umbrella/excess insurance.  Milwaukee County DHHS must be afforded a thirty day (30) written notice of cancellation or non-renewal.  Disclosure must be made of any non-standard or restrictive additional insured endorsement, and any use of non-standard or restrictive additional insured endorsement will not be acceptable.  A certificate indicating the above coverages shall be submitted for review and approval by county for the duration of this agreement.

	Exceptions of compliance with “additional insured” endorsement are:
1.	Transport companies insured through the State “Assigned Risk Business” (ARB).
2.	Professional Liability where additional insured are not allowed.

Contractor shall furnish County annually on or before the date of renewal, evidence of a Certificate indicating the above coverages (with Milwaukee County DHHS named as the “Certificate Holder”) shall be submitted for review and approval by County throughout the duration of this Agreement.  If said Certificate of Insurance is issued by the insurance agent, it is the Contractor’s responsibility to ensure that a copy is sent to the insurance company to ensure that the County is notified in the event of a lapse or cancellation of coverage.

If Contractor’s insurance is underwritten on a Claims-Made basis, the Retroactive date shall be prior to or coincide with the date of this agreement, the Certificate of Insurance shall state that professional malpractice or errors and omissions coverage, if the services being provided are professional services coverage is Claims-Made and indicate the Retroactive Date, Contractor shall maintain coverage for the duration of this agreement and for six (6) years following the completion of this agreement.

It is also agreed that on Claims-Made policies, either Contractor or County may invoke the tail option on behalf of the other party and that the Extended Reporting Period premium shall be paid by the Contractor.

Binders are acceptable preliminarily during the provider application process to evidence compliance with the insurance requirements.

All Coverages shall be placed with an insurance company approved by the State of Wisconsin and rated “A” per Best’s Key Rating Guide.  Additional information as to policy form, retroactive date, discovery provisions and applicable retentions, shall be submitted to County if requested, to obtain approval of insurance requirements.  Any deviations, including use of purchasing groups, risk retention groups, etc., or requests for waiver from the above requirements shall be submitted in writing to the Milwaukee County Risk Manager (Milwaukee County Risk Manager, Milwaukee County Courthouse, Room 302, 901 N. 9th St. Milwaukee, WI  53233) for approval prior to the commencement of activities under the Contract.  

TO BE COMPLETED, SIGNED AND SUBMITTED BY ALL APPLICANTS.   RETAIN A COPY IN AGENCY FILE         	    

YEAR 2008 EQUAL EMPLOYMENT OPPORTUNITY CERTIFICATE                                                                            
FOR MILWAUKEE COUNTY CONTRACTS

In accordance with Section 56.17 of the Milwaukee County General Ordinances and Title 41 of the Code of Federal Regulations, Chapter 60, SELLER or SUCCESSFUL BIDDER or CONTRACTOR or LESSEE or (Other-specify),(Hence forth referred to as VENDOR) certifies to Milwaukee County as to the following and agrees that the terms of this certificate are hereby incorporated by reference into any contract awarded.

Non-Discrimination
VENDOR certifies that it will not discriminate against any employee or applicant for employment because of race, color, national origin, sex, age or handicap which includes but is not limited to the following: employment, upgrading, demotion or transfer, recruitment or recruitment advertising; layoff or termination; rates of pay or other forms of compensation; and selection for training including apprenticeship.	
VENDOR will post in conspicuous places, available to its employees, notices to be provided by the County setting forth the provision of the non-discriminatory clause.
A violation of this provision shall be sufficient cause for the County to terminate the contract without liability for the uncompleted portion or for any materials or services purchased or paid for by the contractor for use in completing the contract.

Affirmative Action Program
VENDOR certifies that it will strive to implement the principles of equal employment opportunity through an effective affirmative action program, which shall have as its objective to increase the utilization of women, minorities, and handicapped persons and other protected groups, at all levels of employment in all divisions of the seller's work force, where these groups may have been previously under-utilized and under-represented.
VENDOR also agrees that in the event of any dispute as to compliance with the aforestated requirements, it shall be his responsibility to show that he has met all such requirements.

Non-Segregated Facilities
VENDOR certifies that it does not and will not maintain or provide for its employees any segregated facilities at any of its establishments, and that it does not permit its employees to perform their services at any location under its control, where segregated facilities are maintained.

Subcontractors
VENDOR certifies that it has obtained or will obtain certifications regarding non-discrimination, affirmative action program and nonsegregated facilities from proposed subcontractors that are directly related to any contracts with Milwaukee County, if any, prior to the award of any subcontracts, and that it will retain such certifications in its files.

Reporting Requirement
Where applicable, VENDOR certifies that it will comply with all reporting requirements and procedures established in Title 41 Code of Federal Regulations, Chapter 60.
Affirmative Action Plan
VENDOR certifies that, if it has 50 or more employees, it will develop and/or update and submit (within 120 days of contract award) an Affirmative Action Plan to: Mr. Amos Owens, Audit Compliance Manager, Milwaukee County Department of Audit, 2711 West Wells Street, Milwaukee, WI 53208  [Telephone No.: (414) 278-4246].
VENDOR certifies that, if it has 50 or more employees, it has filed or will develop and submit (within 120 days of contract award) for each of its establishments a written affirmative action plan.  Current Affirmative Action plans, if required, must be filed with any of the following: The Office of Federal Contract Compliance Programs or the State of Wisconsin, or the Milwaukee County Department of Audit, 2711 West Wells Street, Milwaukee, WI 53208  [Telephone No.: (414) 278-4246].
If a current plan has been filed., indicate where filed                                                                             and the year covered	.
VENDOR will also require its lower-tier subcontractors who have 50 or more employees to establish similar written affirmative action plans.

Employees
VENDOR certifies that it has (No. of Employees) 	employees in the Standard Metropolitan Statistical Area (Counties of Milwaukee, Waukesha, Ozaukee and Washington, Wisconsin) and (No. of Employees) 		employees in total.

Compliance
	VENDOR certifies that it is not currently in receipt of any outstanding letters of deficiencies, show cause, probable cause, or other notification of noncompliance with EEO regulations.

Executed this	day of	, 20	by:	 Firm Name	___________________________________________________________

By: 		Address 	
	(Signature)
	                             City/State/Zip	
                                                                              (Title)                                

SUBMIT THIS DOCUMENT WITH COMPLETED APPLICATION.  POLICY SHALL BE POSTED IN A CONSPICUOUS LOCATION	   

YEAR  2008 EQUAL OPPORTUNITY POLICY

								is in compliance with the equal opportunity policy and standards of the Wisconsin Department of Health and Family Services and all applicable Federal and State rules and regulations regarding nondiscrimination in employment and service delivery.

EMPLOYMENT - AFFIRMATIVE ACTION & CIVIL RIGHTS
It is the official policy of 								 that no otherwise qualified person shall be excluded from employment, be denied the benefits of employment or otherwise be subjected to discrimination in employment in any manner on the basis of age, race, religion, color, sex, national origin or ancestry, handicap, physical condition, developmental disability, arrest or conviction record, sexual orientation, military/veteran status or military participation.  We pledge that we shall comply with Affirmative Action and Civil Rights standards to ensure that applicants are employed and that employees are treated during their employment without regard to the above named characteristics.  Such action shall include but not be limited to the following:  employment, upgrading, demotion, transfer, recruitment, or recruitment advertising, layoff or termination, rates of pay or other forms of compensation and selection for training including apprenticeship.

							has a written Affirmative Action Plan which includes a process by which discrimination complaints may be heard and resolved.

SERVICE DELIVERY - CIVIL RIGHTS
It is the official policy of 							 that no otherwise qualified applicant for services or service recipient shall be excluded from participation, be denied benefits or otherwise be subjected to discrimination in any manner on the basis of age, race, religion, color, sex, national origin or ancestry, handicap, physical condition, developmental disability, arrest or conviction record, sexual orientation, military/veteran status or military participation.  We pledge that we shall comply with civil rights laws to ensure equal opportunity for access to service delivery and treatment without regard to the above named characteristics.							has a written Civil Rights Action Plan which includes a process by which discrimination complaints may be heard and resolved.

All officials and employees of 							are informed of this statement of policy.  Decisions regarding employment and service delivery shall be made to further the principles of affirmative action and civil rights.

To ensure compliance with all applicable Federal and State rules and regulations regarding Equal Opportunity and nondiscrimination in employment and service delivery,				      		has been designated as our Equal Opportunity Coordinator.  Any perceived discrimination issues regarding employment or service delivery shall be discussed with  Ms./Mr.					.  Ms./Mr. 					 may be reached during weekdays at 			.
A copy of the Affirmative Action Plan and/or the Civil Rights Action Plan including the process by which discrimination complaints may be heard and resolved is available upon request.

	(Director or Chief Officer)		(Title)						(Date)

 PROVIDER ASSURANCES AND CERTIFICATIONS

I, 					, agree that all information included in this application is true and correct and that the provider understands and agrees to the application information and requirements.  Provider further acknowledges that the information in this application is subject to periodic verification without notice and that any misrepresentation on this form may result in disqualification from receiving public (CMO) funds and legal action or fiscal sanctions may be taken as determined appropriate by Milwaukee County or its designated representative(s).  Provider understands that completion of provider application does not guarantee network admission and/or subsequent contract with the DSD or the CMO.

I, 					, constitute as the Provider to allow authorized representatives of DHHS and County’s  funding sources to have access to all records necessary to confirm the provision of services by the Provider.  Failure on the part of the Provider to comply with program requirements or not have sufficient documentation to verify provision of the services billed, may result in withholding or forfeiture of any payments.  At a minimum, the Providers must have client records that include:  names and address, the type and dates of service provided, the number of units of service provided, and documentation that service was provided.

The applicant certifies to the best of its knowledge and belief, that it and its principals, owners, partners, shareholders, directors, members or officers of your business entity: (1) are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal department or agency; (2) have not within a three-year period preceding this application have been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; (3) are not presently indicted for or otherwise criminally charged by a governmental entity (Federal, State or local) with commission of any of the offenses enumerated in (2) of this certification; and , (4) have not within a three-year period preceding this application had one or more public transactions (Federal, State or local) terminated for cause or default.

												
Printed Name and Title						

												
Authorized Signature							Date

APPLICATION MUST BE RECEIVED NO LATER THAN FRIDAY, DECEMBER 14, 2007
        
MILWAUKEE COUNTY DEPARTMENT OF HEALTH & HUMAN SERVICES
Contract Administration
1220 W. Vliet Street, Suite 109
Milwaukee, WI.  53205
PHONE: (414) 289-5980 	FAX (414) 289-8574

H:\Contract\DSD Projects\LTS Provider Network Project\DSD LTS Application\Final DSD Provider Application.102307.doc