Exhibit 10.21


 


SECTION 9


ATTACHMENT A


APPLICATION AND QUALIFIED VENDOR
AGREEMENT AWARD


 


	
  APPLICATION
  and

  	
   

  	
  ARIZONA
  DEPARTMENT OF

  
	
   

  	
   

  	
  ECONOMIC
  SECURITY

  
	
  QUALIFIED
  VENDOR AGREEMENT AWARD

  	
   

  	
   

  
	
   

  	
   

  	
  DIVISION
  OF

  
	
  RFQVA
  NO. DDD 704011

  	
   

  	
  DEVELOPMENT
  DISABILITIES

  



 


APPLICATION


 


	
  TO: THE STATE OF ARIZONA

  
	
   

  
	
  The undersigned hereby
  applies and agrees to provide the service(s) in compliance with the RFQVA 

  For clarification of this application, contact:

  



 


	
   

  	
   

  	
   

  
	
  Greg Torres

  	
   

  	
  04-2893910

  
	
  Name

  	
   

  	
  Federal Employer Identification Number

  
	
   

  	
   

  	
   

  
	
  (617) 790-4800

  	
   

  	
  National Mentor Healthcare, Inc. DBA Arizona Mentor

  
	
  Phone Number

  	
   

  	
  Company Name

  
	
   

  	
   

  	
   

  
	
  (617) 790-4901

  	
   

  	
  3724 N. 3rd
  St. Suite 200

  
	
  Fax Number

  	
   

  	
  Mailing Address

  
	
   

  	
   

  	
   

  
	
  greg.torres@TheMentorNetwork.com

  	
   

  	
  Phoenix

  	
  AZ

  	
  85012

  
	
  Email Address

  	
   

  	
  City

  	
  State

  	
  Zip

  
	
   

  	
   

  	
   

  
	
  If awarded a Qualified Vendor Agreement,

  	
   

  	
  602-200-9494

  
	
  all notices should be sent to:

  	
   

  	
  Phone Number

  
	
   

  	
   

  	
   

  
	
  Kay S. Moore

  	
   

  	
  kay.moore@TheMentorNetwork.com

  
	
  Name

  	
   

  	
  E-Mail Address

  
	
   

  	
   

  	
   

  
	
  3724 N. 3rd
  St. Suite 200

  	
   

  	
  /s/ Greg Torres

  
	
  Mailing Address

  	
   

  	
  Signature & Person Authorized to Sign
  Application

  
	
   

  	
   

  	
   

  
	
  Phoenix

  	
  AZ

  	
  85012

  	
   

  	
   

  
	
  City

  	
  State

  	
  Zip

  	
   

  	
  Greg Torres

  
	
   

  	
   

  	
  Printed Name

  
	
  602-200-9494

  	
  602-200-8588

  	
   

  	
   

  
	
  Phone Number

  	
  Fax Number

  	
   

  	
  CEO

  
	
   

  	
   

  	
   

  	
  Title

  
	
  kay.moore@TheMentorNetwork.com

  	
   

  	
   

  
	
  EMail Address

  	
   

  	
   

  
								



 


APPROVAL OF APPLICATION AND
AGREEMENT AWARD (FOR STATE OF ARIZONA USE ONLY)


 


Your application is hereby approved. 
The Qualified Vendor is now bound to provide the service (s) listed in
the attached award notice based upon the RFQVA, including all terms,
conditions, service specifications, scope of work, amendments, etc., and the
Qualified Vendor’s application as accepted by the State.


 


This agreement shall henceforth be referred to as Qualified Vendor
Agreement No. 00455. The begin date and the effective date of this agreement
is either the date that this award is signed by the Procurement Officer or
July 1, 2003, whichever is later.


 


	
   

  	
  State of Arizona

  	
   

  
	
   

  	
  Awarded this Date:

  	
  7/1/03

  	
   

  
	
   

  	
  /s/ Antonia Valladares

  	
   

  
	
   

  	
  Procurement Officer

  	
   

  
					



 


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SECTION 1



NOTICE
OF REQUEST FOR QUALIFIED VENDOR APPLICATIONS (RFQVA)


State of
Arizona


Department
of Economic Security (DES) or (Department) 


Division
of Developmental Disabilities (DDD) or (Division)


 


RFQVA
Number: DDD 704011


 


o Time Limited


ý Open and Continuous


 


Application Due Date:


 


Pursuant to Arizona Revised Statutes (A.R.S.) § 36-557 and
rules adopted thereunder (R6-6-2101 et seq.), which are incorporated
herein by reference, Applications for the services listed below will be
accepted by the Division at the time and manner specified below. Through this
Request for Qualified Vendor Applications (RFQVA) the Arizona Department of
Economic Security (DES or Department), Division of Developmental Disabilities
(DDD or Division) will execute Qualified Vendor Agreements with providers for
the provision of services.


 


Applications must be submitted electronically using the Qualified
Vendor Application and Directory System as well as submitting a printable hard
copy with signatures and necessary additional documentation. See Section 3
and Section 9.


 


Applications will be accepted from current contracted
providers beginning April 7, 2003. To assure service continuation
effective July 1, 2003 Applications should be submitted by May 1,
2003 at 5 p.m. Arizona time. Applicants new to DDD may submit
Applications beginning May 5, 2003. All Applicants shall not expect to be
awarded an agreement sooner than 60 days after the submittal of a complete
Application. [NOTE: Applications from independent providers as defined in
Section 6 will not be processed or result in an agreement until the
statewide published rates for independent providers have been adopted in the
fall of 2003.]


 


Submittal
Location:


 


ELECTRONICALLY
GENERATED HARD COPY WITH ORIGINAL SIGNATURE 


AND
NECESSARY DOCUMENTATION


 


In Person or By Courier
to:


 


DDD Contract Unit, 4th
Floor Southwest


Business Operations —
Site Code 791A


Division of Developmental
Disabilities


Arizona Department of
Economic Security


1789 West Jefferson
Street


Phoenix, Arizona 85007


(602) 542-6874


 


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By Mail to:


 


DDD Contract Unit


Business Operations -
Site Code 791A


Division of Developmental
Disabilities


Arizona Department of
Economic Security


P.O. Box 6123


Phoenix, Arizona 85005


 


Services:


 


Home-Based Services: Attendant Care; Habilitation, Community Protection
and Treatment Hourly; Habilitation, Support; Housekeeping; and Respite. Day Treatment and Training Services:
Day Treatment and Training, Adult; Day Treatment and Training, Children
(After-School); and Day Treatment and Training, Children (Summer). Developmental Home Services:  Habitation, Vendor Supported Developmental
Home (Child and Adult); and Room and Board, Vendor Supported Developmental
Home (Child and Adult). Independent Living
Services: Habilitation, Individually Designed Living
Arrangement. Group Home Services:
Habilitation, Community Protection and Treatment Group Home; Habilitation,
Group Home; Habilitation, Nursing Supported Group Home; and Room and
Board, All Group Homes. Professional Services:
Home Health Aide; Nursing; Occupational Therapy; Occupational Therapy Early
Intervention; Physical Therapy; Physical Therapy Early Intervention; Speech
Therapy; and Speech Therapy Early Intervention. Other
Services: Transportation.


 


First
Pre-Application Conference:


 


Date: March 19, 2003, Arizona Time: 10 a.m.
to 2 p.m.


 


Location:                      Sheraton Crescent Hotel


2620 West Dunlap Avenue 


Phoenix, Arizona 


(602) 943-8200


 


Second
Pre-Application Conference:


 


The second pre-Application conference will be held
after the electronic application is released. The purpose of the conference
will be to answer specific questions about the electronic application, referred
to as the Qualified Vendor
Application and Directory System.


 


Date: March 28, 2003, Arizona Time: Session
1 - 9 a.m. to Noon; Session 2 - 1 p.m. to 4 p.m.


 


These two sessions will provide the same information. Applicants whose
Federal Employer Identification Number (FEIN) or Social Security Number (SSN)
ends with an odd number shall attend the morning (9 am to noon) session, and
Applicants whose FEIN or SSN ends with an even number shall attend the
afternoon (1 p.m. to 4 p.m.) session.


 


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Location:                      Auditorium in the basement of the Arizona
Land Department 


1616 West Adams Street 


Phoenix, Arizona 


(602) 542-4631


 


Persons with a disability may request a reasonable
accommodation by contacting the RFQVA contact person. (For TDD/TTY call
through the Arizona Relay Service at 800 367-8939). Requests should be made
as early as possible to allow time to arrange the accommodation.


 


Agreement Type: Qualified Vendor Agreement with
Published Rate


 


Agreement Term: 12 months beginning no sooner than 7/1/03, with five
one-year options for the Division to extend or renew the agreement, with all
agreements ending 6/30/09. The agreement can be terminated as specified in
Section 6, DES/DDD Terms and Conditions.


 


RFQVA Contact Person (Phone/email)


 


Cathie Rodman (602)
542-6896 /CRodman@azdes.gov


 


 


	
   

  	
   

  	
   

  	
   

  
	
  DDD Procurement Specialist

  	
  Date

  



 


AN EQUAL
EMPLOYMENT OPPORTUNITY AGENCY


 


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