S02_SOL_Att1_Contractor_Information_676-19-107_Replace_Med_Vac_Pump.docx
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- Solicitation number
- 36C25219B0017
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36C25219B0017 S02 SOL Att1 Contractor Information 676-19-107 Replace Med Vac Pump.docx
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| Solicitation 36C25219B0017 | Attachment 1 | |
| Project 676-19-107 Replace Medical Vacuum Pump B400 | Page 1 of 1 |
CONTRACTOR INFORMATION
| Name of Company: | ___________________________________________ |
| Address: | ___________________________________________ |
| City, State, Zip Code: | ___________________________________________ |
| Name(s) and Title of Company | 1.) ________________________________________ |
| Signatory, Legal Binding | 2.) ________________________________________ |
| Authority(s) | 3.) ________________________________________ |
| 4.) _______________________________________ |
| Primary Point of Contact: | ___________________________________________ |
| E-Mail Address: | ___________________________________________ |
| Address: | ___________________________________________ |
| City, State, Zip Code: | ___________________________________________ |
| Phone No: | ___________________________________________ |
| Fax No: | ___________________________________________ |
| TAX ID Number: | ___________________________________________ |
| DUNS Number: | ___________________________________________ |
Past Performance Point of Contact (within your company), include name and email address:
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