09-250-SOL-00083.pdf

OMB No. 0990-0115

09-250-SOL-00083

1. REQUEST NO.

5a. ISSUED BY

NAME

a. NAME

c. STREET ADDRESS

d. CITY

10. PLEASE FURNISH QUOTATIONS TO

THE ISSUING OFFICE IN BLOCK 5a ON

OR BEFORE CLOSE OF BUSINESS (Date)

2. DATE ISSUED 3. REQUISITION/PURCHASE REQUEST NO. 4. CERT. FOR NAT. DEF.

UNDER BDSA REG. 2

AND/OR DMS REG.1

RATING

6. DELIVERY BY (Date)

7. DELIVERY

9. DESTINATION

a. NAME OF CONSIGNEE

b. STREET ADDRESS

PAGE OF PAGES

5b. FOR INFORMATION CALL: (No collect calls)

TELEPHONE NUMBER

AREA CODE NUMBER

8. TO:

b. COMPANY

e. STATE f. ZIP CODE

c. CITY

d. STATE e. ZIP CODE

IMPORTANT: This is a request for information, and quotations furnished are not offers. If you are unable to quote, please so indicate on this form and return it to the address in Block 5a. This request does not commit the Government to pay any costs incurred in the preparation of the submission of this quotation or to contract for supplies or services. Supplies are of domestic origin unless otherwise indicated by quoter. Any representations and/or certifications attached to this Request for Quotations must be completed by the quoter.

11. SCHEDULE (Include applicable Federal, State and local taxes)

THIS RFQ

REQUEST FOR QUOTATION

(THIS IS NOT AN ORDER)

IS IS NOT A SMALL BUSINESS SET ASIDEX

07/06/2009 HRS6294

1 2

Division Of Procurement Management 5600 Fishers Lane, Rm 13A-19 Rockville MD 20857

HRSA/OFM/DPM

Health Resources and Services Admin

Health Resources and Services Admin 5600 Fishers Lane

Rockville

MD 20852

301 443-0611KWASI ANTWI

07/20/2009 1600 ES

FOB DESTINATION

OTHER

(See Schedule)X

ITEM NO.

(a)

SUPPLIES/SERVICES

(b)

QUANTITY

(c)

UNIT

(d)

UNIT PRICE

(e)

AMOUNT

(f)

PLEASE COMPLETE THIS FORM, PROVIDE A PRICE QUOTE

BASED ON THE STATEMENT OF WORK OR THE LINE

ITEM(S) BELOW, AND PROVIDE THE FOLLOWING

INFORMATION:

1. CONTACT NAME, PHONE & FAX

NUMBER:______________

2. E-MAIL:__________________________

3. DUNS NUMBER: ________________

4. TAX IDENTIFICATION NUMBER: _______________

5. GSA SCHEDULE NUMBER (IF APPLICABLE): ______

The purpose of this procurement is to produce an annual white paper on key findings and the state of agricultural health and safety issues in rural America. Given the high rate of injury and the Continued ...

12. DISCOUNT FOR PROMPT PAYMENT

a. 10 CALENDAR DAYS (%) b. 20 CALENDAR DAYS (%) c. 30 CALENDAR DAYS (%) d. CALENDAR DAYS

NUMBER PERCENTAGE

NOTE: Additional provisions and representations

13. NAME AND ADDRESS OF QUOTER

b. STREET ADDRESS

c. COUNTY

d. CITY e. STATE f. ZIP CODE

14. SIGNATURE OF PERSON AUTHORIZED TO

SIGN QUOTATION

16. SIGNER

a. NAME (Type or print)

c. TITLE (Type or print)

a. NAME OF QUOTER

AREA CODE

NUMBER

15. DATE OF QUOTATION

b. TELEPHONE are are not attached

AUTHORIZED FOR LOCAL REPRODUCTION

Previous edition not usable

STANDARD FORM 18 (REV. 6-95)

Prescribed by GSA - FAR (48 CFR) 53.215-1(a)

OMB No. 0990-0115

ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

NAME OF OFFEROR OR CONTRACTOR

2 2

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

(A) (B) (C) (D) (E) (F)

09-250-SOL-00083

diverse nature of farms in the United States, the

Office of Rural Health Policy at the Health

Resources and Services Administration has identified a need to work with States to promote occupational health and safety on American farms.

This project seeks to create a partnership with a contractor and community entities to share information and train community-based health care providers in how to assess risk factors on farms so as to reduce the rate of illness and injury.

1 See Statement of Work

NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)