RepsCerts2120.pdf

INL FORM

PROC-2120

(Rev. 08/30/2010)

PROPOSAL/CERTIFICATION FORM FOR RFP NO. 00______

Date: _______________________________

From: ______________________________________________________________________________ Company

Street Address/P.O. Box

City/State/Zip Code

Contact

E-Mail Address

Phone: ______________________________

Fax: ______________________________

Response to Request for Proposal No. 00______

1. Price

No. Qty UOM Description Unit Price Extended Price

1.1. $__________________ Ceiling Price

1.2. $__________________ Minus Prompt Payment Discount in Section 3, Cash Terms

1.3. $__________________ Net Evaluated Price Ceiling

1.4. Note: Offeror shall attach fully-burdened hourly labor rate(s) and proposed hours for each person and/or labor category

2. Completion

2.1. Date (or days/weeks after receipt of Contract): ____________________________

3. Cash Terms

3.1. (_) Prompt Payment Discount: ___% for Payment within 15 Days

3.2. (_) No Prompt Payment Discount: Net 30 Days

3.3. BEA utilizes the Automated Clearing House (ACH) to process payments. The Offeror shall complete and submit Form 534.28, Direct Deposit Authorization Form and forward a completed copy to acctpay@inl.gov. (Form is available at https://inlportal.inl.gov/portal/server.pt/community/procurement/346/documents_and_forms)

4. Proposal Expiration: (See Proposal Instructions)

4.1. (_) 90 Days (_) Other _____________________ (Date)

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Rev. 08/30/2010

Battelle Energy Alliance, LLC RFP No. 00______

5. Business Type Certification:

5.1. (_) Corporation (_) Partnership (_) Individual (_) Sole Proprietorship (_) Non-resident foreign individual, foreign partnership, foreign corporation, or foreign non-profit entity

5.2. If Offeror certifies its business type to be "Individual", "Offeror" further certifies that Offeror is not a participant in a BEA Retirement Plan. If Offeror is participating in a BEA Retirement Plan, Offeror shall notify BEA prior to award.

5.3. State: ___________

6. Socioeconomic Classification: As currently defined by the Small Business Administration, Offeror certifies it is a:

6.1. (_) Small: Select applicable business classification(s)

6.1.1. (_) Native-American Business

6.1.2. (_) Woman-owned Business

6.1.3. (_) Disadvantaged [(_) 8(a) (_) non-8(a)] Business*

6.1.4. (_) 8a Business*

6.1.5. (_) HUB Zone Business*

6.1.6. (_) Veteran Owned [(_) Service Disabled]

6.1.7. (_) None of the Above

6.1.8. *Note: Offeror may be requested to provide a copy of the Small Business Certification letter

6.2. (_) Large Business

6.3. (_) Sheltered workshop

6.4. (_) Non-profit Business

6.5. (_) Educational Institution

6.6. North American Industrial Classification System (NAICS) Code: 541712

6.7. Size Standard: 500 Employees

6.8. Description: Research and Development in the Physical, Engineering, and Life Sciences

7. Environmental Protection Agency (EPA): Offeror certifies that any facility to be utilized in the performance of the proposed Contract has not been listed on the Environmental Protection Agency (EPA) List of Violating Facilities. Offeror will promptly notify BEA, prior to award, of the receipt of any communication from the Director, Office of Federal Activities, EPA, indicating that any facility it proposes to use for the performance of the Contract is under consideration to be on the EPA List of Violating Facilities. Offerors will include this certification, including this sentence, in every nonexempt lower-tier contract.

8. Identification

8.1. DUNS Number: __________________________

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Rev. 08/30/2010

Battelle Energy Alliance, LLC RFP No. 00______

8.2. Federal Tax ID or SS#: __________________________

8.3. Principal Place of Performance: __________________________

9. GSA List of Excluded Parties: The Offeror or its principals certify it does not appear on the GSA List of Parties Excluded From Federal Procurement or Nonprocurement Programs and is not proposed for debarment by the Federal Government. If Offeror is currently debarred or proposed for debarment, Offeror shall notify BEA prior to award.

10. Addendum(a) (if applicable): The undersigned acknowledges the receipt of the following addendum(a): __________________

Offeror's Signature: _______________________________________________________________

Offeror's Printed Name: _______________________________________________________________

Title: _______________________________________________________________

Date: _______________________________________________________________

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