3-RFP-03-Authorized Signature and Questionnaire.pdf

CITY OF FORT WORTH - PURCHASING DIVISION

AUTHORIZED SIGNATURE AND QUESTIONNAIRE

RFP Ref. #: 26-0066 Doc. Ref#: RFP-04 Page 1 of 2 RFP Title: EMS Billing Services

City of Fort Worth Bidder/Supplier ID:____________________________________ Legal Name of Proposer:

D/B/A Name of Proposer:

Federal Id Number (TIN):______________________________________________ Address:

Name of the Authorized Representative: __________________________________ Title: _____________________________________________________________ The undersigned, by his/her signature, represents that he/she is submitting a binding Proposal and is authorized to bind the respondent to fully comply with the solicitation document contained herein. The Respondent, by submitting and signing below, acknowledges that he/she has received and read the entire document packet for this RFP and agrees to be bound by the terms therein.

The undersigned agrees if the Proposal is accepted, to furnish any and all items and/or services upon which prices are offered, at the price(s) and upon the terms, conditions, and scope/specifications contained in this RFP.

Signature of the Authorized Representative: _____________________________ Email: Phone:

Name of Contact Person - 1:

Title of Contact Person - 1:

Email: Phone:

Name of Contact Person - 2:

Title of Contact Person - 2:

Email: Phone:

Name of Contact Person - 3:

Title of Contact Person - 3:

Email: Phone:

CITY OF FORT WORTH - PURCHASING DIVISION

AUTHORIZED SIGNATURE AND QUESTIONNAIRE

RFP Ref. #: 26-0066 Doc. Ref#: RFP-04 Page 2 of 2 RFP Title: EMS Billing Services

Please answer each question below thoroughly. Responses to the questions will be used to assess the Proposal’s responsiveness. Bidders may use a separate sheet if needed, as long as each answer is labeled with the corresponding question number.

1.0 Length of time in business: _______________________________________

2.0 Is your business or any of its principals currently involved in litigation adverse to the City? Yes_______ No________

3.0 Is your business or any of its principals under criminal investigation?

Yes_______ No________ Have you answered Yes to either Question 1 or 2 above? Please provide the details outlining the situation on a separate document with the submission of this form.

4.0 Cooperative Purchasing - Should other governmental entities decide to participate in this contract, would you, the Vendor, agree that all terms, conditions, specifications, and pricing would apply?

Yes_______ No________

5.0 Prompt Payment Discount Terms: ____ Percent _______ Days (i.e. 3% Net 15, etc.)

6.0 Proprietary Information - If a Bidder believes certain information in their proposal is proprietary and wishes to prevent its disclosure, they must clearly identify those pages and information in the chart below, for more information see RFP-01, Section 15.4.

Pages with information believed to be Proprietary

Please indicate if only specific sections on the page are believed to be Proprietary