3-HSS-26-037 -Non Colluison Statement Form -Attachment 2.pdf
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- Solicitation number
- HSS-26-037
- Issued by
- Delaware
About this file
This is a Non-Collusion Statement Form attachment for the Delaware Health and Social Services Division of Public Health, specifically for Contract No. HSS-26-037 regarding Interviewing Services for the Delaware Adult Tobacco Survey. The vendor is required to certify that it has not engaged in collusion, anti-competitive agreements, or restraint of free competitive bidding in connection with this proposal. The form requires completion by an authorized representative who has legal authority to bind the organization into a contract with the State of Delaware. The deadline to respond is April 21, 2026, at 1:00 PM EST/EDT. The survey is an annual telephone interview initiative targeting non-institutionalized Delaware residents age 18 and older, utilizing both landline and cell phone samples to assess tobacco use prevalence and related factors. The selected vendor will be responsible for administering the survey, calculating sampling, and conducting data analysis to support the Division's Tobacco Prevention and Control Program evaluation and planning efforts.
The form requires vendors to provide company information, contact details, federal E.I. number, and license number, along with identification of any relevant business certifications including Minority Business Enterprise (MBE), Woman Business Enterprise (WBE), Disadvantaged Business Enterprise (DBE), Veteran Owned Business Enterprise (VOBE), and Service-Disabled Veteran Owned Business Enterprise (SDVOBE) status. Vendors must also affirm whether their firm, any affiliate, predecessor company, or key personnel have been subject to federal, state, or local government suspension or debarment within the past five years. The form includes designation of a primary contact for purchase order delivery. No pricing information, set-asides, incumbent vendor data, or funding amounts are specified in this attachment.
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Text version
Delaware Health and Social Services Division of Public Health
Attachment 2
CONTRACT NO.: HSS-26-037
CONTRACT TITLE: Interviewing Services for the Delaware Adult Tobacco Survey DEADLINE TO RESPOND: April 21, 2026, at 1:00 PM EST/EDT
NON-COLLUSION STATEMENT (COMPLETE THIS FORM IN ITS ENTIRETY)
This is to certify that the undersigned Vendor has neither directly nor indirectly, entered into any agreement, participated in any collusion or otherwise taken any action in restraint of free competitive bidding in connection with this proposal, and further certifies that it is not a sub-contractor to another Vendor who also submitted a proposal as a primary Vendor in response to this solicitation submitted this date to the State of Delaware, Division of Public Health.
It is agreed by the undersigned Vendor that the signed delivery of this bid represents, subject to any express exceptions set forth at Attachment 3, the Vendor’s acceptance of the terms and conditions of this solicitation including all specifications and special provisions.
NOTE: Signature of the authorized representative MUST be of an individual who legally may enter his/her organization into a formal contract with the State of Delaware, Division of Public Health.
COMPANYNAME (Check one)
NAME OF AUTHORIZED REPRESENTATIVE
(Please type or print)
SIGNATURE TITLE
COMPANY ADDRESS
PHONE NUMBER FAX NUMBER
EMAIL ADDRESS ______________________________
STATE OF DELAWARE
FEDERAL E.I. NUMBER LICENSE NUMBER_____________________________
COMPANY
CLASSIFICATIONS:
CERT. NO.:
Certification type(s) Circle all that apply
Minority Business Enterprise (MBE) Yes No Woman Business Enterprise (WBE) Yes No Disadvantaged Business Enterprise (DBE) Yes No Veteran Owned Business Enterprise (VOBE) Yes No Service-Disabled Veteran Owned Business Enterprise (SDVOBE) Yes No
[The above table is for informational and statistical use only.]
PURCHASE ORDERS SHOULD BE SENT TO:
(COMPANY NAME)
ADDRESS
CONTACT
PHONE NUMBER FAX NUMBER
EMAIL ADDRESS
AFFIRMATION: Within the past five years, has your firm, any affiliate, any predecessor company or entity, owner, Director, officer, partner or proprietor been the subject of a Federal, State, Local government suspension or debarment?
YES NO if yes, please explain
Corporation Partnership Individual
File details come from the government source that posted it. Updated .