RFQ.pdf

PAGE OF PAGES

THIS RFQ IS IS NOT A SMALL BUSINESS SET-ASIDE

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

UNDER BDSA REG. 2

AND/OR DMS REG. 1

5A. ISSUED BY 6. DELIVER BY (Date)

5B. FOR INFORMATION CALL: (No collect calls) 7. DELIVERY

NAME TELEPHONE NUMBER FOB DESTINATION (See Schedule)

OTHER

AREA CODE NUMBER 9. DESTINATION

a. NAME OF CONSIGNEE

8. TO:

a. NAME b. COMPANY b. STREET ADDRESS

c. STREET ADDRESS c. CITY

d. CITY e. STATE f. ZIP CODE d. STATE e. ZIP CODE

10. PLEASE FURNISH QUOTATIONS TO THE ISSUING OFFICE ON

OR BEFORE CLOSE OF BUSINESS (Date)

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. 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.

ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

(a) (b) (c) (d) (e) (f)

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

NUMBER PERCENTAGE

NOTE: Additional provisions and representations are are not attached.

13. NAME AND ADDRESS OF QUOTER 14. SIGNATURE OF PERSON AUTHORIZED TO SIGN QUOTATION 15. DATE OF QUOTATION

a. NAME OF QUOTER

b. STREET ADDRESS 16. SIGNER

a. Name (Type or print) b. TELEPHONE

c. COUNTY AREA CODE

d. CITY e. STATE f. ZIP CODE c. TITLE (Type or print) NUMBER

IMPORTANT:

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

12. DISCOUNT FOR PROMPT PAYMENT

(THIS IS NOT AN ORDER)

AUTHORIZED FOR LOCAL REPRODUCTION STANDARD FORM 18 (REV. 6-95)

Previous edition not usable Prescribed by GSA-FAR (48 CFR) 53.215-1(a)

REQUEST FOR QUOTATIONS

1 1

X

246-2016-Q-0027

06/29/2016

Oklahoma City Area Indian Health Service 701 Market Drive Oklahoma City, OK 73114

1 year from Award Date

Katrina Eaton Fax: 405.951.3771 katrina.eaton@ihs.gov 405 951.3704

(To Prospective Offerors)

Wewoka Indian Health Center

P.O. Box 1475

Wewoka

OK 74884

July 15, 2016 4:30pm CST

Contractor shall provide chiropractic services to the Wewoka Indian Health Center in Wewoka, OK.

Please provide the hourly rate.

Base Year

Option Year 1

FAR Clause 52.204-7. System for Award Management does apply

Questions pertaining to this RFQ are due by 4:30 pm CST on Thursday July 7, 2016.

HR $

HR $

X mailto:katrina.eaton@ihs.gov