Attachment 3 - Quote Submission Form SAM.gov.pdf

United States Department of Agriculture

Research, Education, and Economics Agricultural Research Service

Office of the Director ● Midwest Area Administrative Office Acquisitions & Personal Property/Fleet Team

1815 North University Street ● Peoria, IL 61604 USDA is an Equal Opportunity Provider and Employer

QUOTE SUBMISSION FORM

Solicitation Title: ______________________________________________________________

Solicitation Number: _________________

Company Information:

Currently Registered and Active in the System for Award Management (SAM): ( ) Yes ( ) No

SAM Unique Entity Identifier (UEI) Number:

Company Legal Name: _____________________________________________

Doing Business As (if applicable): ____________________________________

Company Address as registered in the System for Award Management (SAM):

CAGE Code(s):

Socio-economic status for the NAICS code: __________ (with a small business threshold of under ______________) – please check ALL that apply:

( ) Small Business Concern [ ] Disadvantaged

[ ] SBA-certified 8(a) Program Participant [ ] SBA-certified HUB Zone Business

[ ] Veteran Owned [ ] Service-Disabled Veteran Owned

[ ] Woman-Owned [ ] Economically Disadvantaged Woman Owned

( ) Other Than Small Business Concern

( ) I confirm that my company is registered in the System for Award Management (SAM) with the socio-economic status identified above and the NAICS code specified or that my firm qualifies for the selected the socio-economic status under the applicable NAICS code.

Agricultural Research Service

Office of the Director ● Midwest Area Administrative Office Acquisitions & Personal Property/Fleet Team

1815 North University Street ● Peoria, IL 61604 USDA is an Equal Opportunity Provider and Employer

Quote Information:

Quote Number: _________________

Quote Date:

Quote Expiration Date:

Quoted Prices:

Vendors shall insert pricing/data in the cells below. All line items must be priced.

Line item Total Amount is the Quantity multiplied by the Unit Price.

Line Item

Item Description Quantity Unit Unit Price Total Amount

In unit value should be EA for each, BX for box

Time to Delivery: ( ) days ( ) weeks ( ) months

Country of Manufacture Information:

Product Name(s) and Part Number(s):

Manufacturer’s Legal Name:

Product is Manufactured in the United States of America (is a domestic product): ( )Yes ( )No

Manufacturing Address (for domestic products*):

Agricultural Research Service

Office of the Director ● Midwest Area Administrative Office Acquisitions & Personal Property/Fleet Team

1815 North University Street ● Peoria, IL 61604 USDA is an Equal Opportunity Provider and Employer

Country of Origin (for nondomestic products):

( ) I confirm that a written certification of the above information was obtained from the product’s manufacturer and is included in the support documents submitted with this quote.

Certification:

I understand that incomplete sections, failure to provide all required documentation, and/or failure to sign this certification may remove my company’s quote from being put into consideration by the Government for award.

Signature:

Name:

Title:

Contact Information:

Date: