Work Centers Application Form

Purpose of Application Form:

In order to qualify as a Work Center and thus be eligible to bid on products and services purchased by the State of Maine that are set-aside exclusively, for Work Centers, this form must be submitted annually and submitted to:

WORK CENTER PURCHASES COMMITTEE
C/O DIRECTOR OF THE DIVISION OF PURCHASES
#9 STATE HOUSE STATION
AUGUSTA, MAINE 04333-0009

Name of Work Center:

___________________________________________________________

Address of Work Center:

___________________________________________________________

Name of Sponsoring Agency (if different):

___________________________________________________________

Agency of Sponsoring Agency: (if different):

___________________________________________________________

I, the undersigned, do hereby declare that the above-named Work Center:

Is currently certified by the United States Department of Labor or the Maine Department of Labor as a Regular Work Program, and/or a Work Activity Center;
Complies with the provision of United States and Maine Occupational Health and Safety Laws:
Employs disabled persons to provide at least 66% of all hours of labor on all production and service work which is used to train or employ disabled persons, and,
Has, or is part of, an on-going placement program which includes a pre-admission evaluation and annual review of each disabled worker's capability for competitive employment, and maintenance of liaison with appropriate community job placement services.

In the event that during the next one-year period the above-cited statement no longer is valid, the work Center Purchases Committee will be notified by mail of this fact within seven days.

Signed by:

_________________________________

Date Signed:

_________________________________

Title or Position of Person Signing:

_______________________________________________

(Must be signed by the President of the Board of Directors or the Work Center or sponsoring agency, or by the person having legal authorization to represent the Board of Directors.)

WORK CENTER QUESTIONNAIRE

Work Center Name: ___________________________________________________________

Mailing Address: ______________________________________________________________

Telephone: __________________________________________________________________

To The Following Questions, Please Check Yes Or No
Question	Yes	No
1. Does your agency have a current: (Please Attach Copy)
a. Regular Work Program Certificate from the US Dept. of Labor?
b. Work Activities Center Certificate from the US Dept. of Labor?

2. Does your agency comply with Occupational Health and Safety Standards Required by US and Maine Laws?

3. Does your agency employ disabled persons to perform at least 66% of all labor on production or service provision?

4. Does your agency have an ongoing job placement program which includes annual evaluation of each disabled worker's capability for competitive employment and arrangements for job placement as needed?

5. Please identify those goods/services which you believe your Work Center presently

provides or could provide. (Attach additional pages, if necessary.)

Presently provides: ____________________________________________________

_____________________________________________________________________

Could Provide:_________________________________________________________

______________________________________________________________________

Name of Person Completing Form

____________________________________

Title of Person Completing Form

____________________________________

Date

____________________________________

DIVISION INFORMATION

INFORMATION

Work Centers Application Form