08 - 36C10F20R0061 - Offering Entity Acknowledgement Form.docx
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Attachment G
REQUEST FOR LEASE
PROPOSALS (RLP)
| COMMUNITY BASED OUTPATIENT CLINIC |
| JUNE 2020 |
| (CBOC) |
| RLP No. 36C10F-20-R-0061 |
BRICK, NEW JERSEY
Offering Entity Acknowledgement for RLP No.: 36C10F-20-R-0061
The Offeror attests that the information provided below is accurate and shall be a basis for evaluation in RLP No.: 36C10F-20-R-0061. Failure to provide the required information may deem your proposal non-responsive.
Offeror Information
Offering Entity Name:
Address:
Offering Entity DUNS Number:
Offering Entity Tax Identification Number:
Authorized Official Name:
Authorized Official Phone Number:
Authorized Official E-mail:
| Authorized Official is Listed in Entity SAM Representations: | |_| Yes |_| No |
| Authorized Official is Listed in Entity Operating Agreement: | |_| Yes |_| No |
Date of Submission:
Time Specified for Receipt of Offers:
| Offering Entity/Prime Contractor Size Status: | SDVOSB | |_| |
| VOSB | |_| | |
| SB | |_| |
Offering Entity Currently Certified in SAM under NAICS 531120 |_|
Offering Entity Currently Verified in VetBiz |_|
| ________________________ | ____________ | |
| Offering Entity POC Signature | Date |
Offering Entity POC Name
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