2025 DOC-2818 Contractor Compliance Agreement (5) (3).docx.pdf
PDF 335 KB Posted
- Attached to
- Medical Gases and Industrial Gases
- Contract number
- 410014-M22-CJO8129-COP-01
- Issued by
- Wisconsin
About this file
This document is a Contractor Compliance Agreement between the Wisconsin Department of Corrections (DOC) and Airgas USA, LLC – North Central Region. The agreement was executed on December 5, 2024, by Linda Wissink, Vice President of Healthcare for Airgas USA, with the company located at 3011-B East Capital Dr., Appleton, WI 54911. The form serves as a compliance certification where the contractor agrees to provide all services consistent with DOC contract terms and affirms compliance with background check requirements for all contractor staff and applicants.
The agreement covers contract number 410014-M22-CJO8129-COP-01 currently held between Airgas USA and the Wisconsin DOC. While the specific goods or services are not detailed in this compliance document, the agreement establishes that the contractor will maintain ongoing compliance with all contract terms throughout the contract life. The document includes a provision that allows this single compliance form to cover any additional contracts the contractor may enter into with the DOC prior to its expiration, eliminating the need for multiple compliance submissions.
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Text version
DEPARTMENT OF CORRECTIONS WISCONSIN
Division of Management Services DOC-2818 (Rev. 9/2022)
DISTRIBUTION: Original – Contractor File (electronic)
CONTRACTOR COMPLIANCE AGREEMENT
INSTRUCTIONS: If you are completing the form through DocuSign, a copy will be automatically forwarded to the email address listed below.
If you are not completing the form through DocuSign, return the completed form to the email address listed below.
CONTRACTOR NAME: Airgas USA, LLC – North Central Region
CONTRACT COMPLIANCE
The contractor hereby agrees that as a contractor who provides services to the State of Wisconsin Department of Corrections (DOC), they will ensure that the contractor and all contractor staff shall provide any and all contracted services in a manner consistent with each DOC contract.
CONTRACTOR STAFF & APPLICANT BACKGROUND CHECKS
Furthermore, the contractor affirms compliance with all Contract Terms and Conditions concerning all provisions relating to background checks of all contractor staff and applicants.
Authorized Contractor Representative Information:
NAME Linda Wissink
POSITION TITLE Vice President of Healthcare
CONTRACTOR
ADDRESS 3011-B East Capital Dr., Appleton, WI 54911
CONTRACTOR PHONE CONTRACTOR EMAIL linda.wissink@airgas.com
List all contract(s) currently held with DOC (include contract identification numbers for proper routing):
Contract Number: 410014-M22-CJO8129-COP-01
If contractor enters into any other contract(s) with the DOC prior to the expiration of this statement of compliance, the contractor need not submit an additional compliance form. This completed form shall cover all contract(s) the contractor has with the DOC, following the date signed by the authorized contractor representative identified above.
During the life of the contract(s), the contractor shall continue to maintain compliance as per the terms of the contract(s).
SIGNATURE DATE SIGNED
Return completed and signed form to: DOCContractCompliance@wisconsin.gov
Docusign Envelope ID: 5A18A4E8-E694-4AD5-BC5F-023C1845409B
12/5/2024
X
920-757-2341
X mailto:linda.wissink@airgas.com
| 2024-12-09T06:20:25-0800 | |
| Digitally verifiable PDF exported from www.docusign.com |
File details come from the government source that posted it. Updated .