26-10-0422_Manufacturer_Certification_Form.pdf

Manufacturer Certification Form

Heavy Equipment Bid 26-10-0422

This form is to be completed for all manufacturers in which your company is bidding.

Vendor (Bidder):

PLEASE NOTE: This certification form must be executed by an authorized employee of the manufacturer ONLY. Dealers/Representatives are not authorized to execute this certification form on behalf of the manufacturer. The manufacturer must execute this certification form even if they are offering their own products. Failure to submit this certification form with your response as required shall result in the disqualification of the response.

The section below is to be completed by the manufacturer representative.

This is to certify that the above vendor/bidder is the manufacturer and/or a manufacturer’s authorized dealer for the following manufacturer in the State of North Carolina.

Manufacturer Name:

Address:

City, State, Zip:

Contact Information of Representative:

Office Phone: Mobile Phone:

E-mail:

Signature of Manufacturer Representative: Title:

Printed Name of Manufacturer Representative: Date:

Note: Signatures must be physical or timestamped.