5. Offeror Info Page.pdf

(Attachment # 5)

REQUEST FOR QUOTE

CRYPTOCURRENCY MANAGEMENT AND DISPOSAL SERVICES

SOLICITATION NO.: 15M50020QA4400006

OFFEROR’S INFORMATION PAGE

Each company shall complete this page and submit as the first page of their proposal.

Offeror’s Name (include ‘Doing Business As’ (DBA) and/or ‘Limited Liability Corporation’ (LLC) if applicable):

Offeror’s Address: ____________________________________________________

Offeror’s Email and Website: ____________________________________________________

Phone Number: ____________________________________________________

Fax Number: ___________________________________________ Dun’s Number: ___________________________________________ Federal Tax I.D. Number: ___________________________________________

Business Size (check all that apply): _____ Small Business

_____ Other than Small

_____ Disadvantaged

_____ Women-Owned

_____ HUBZone

_____ Service-Disabled Veteran-Owned

_____ Women-Owned Small Business (WOSB) Eligible

Under the WOSB Program

_____ EDWOSB

_____ 8(a) Certified Small Business

I, ______________________________________________, represent that, to the best of my knowledge and belief, the information included in my offer is complete, accurate, and true.

Signature Date

OFFEROR’S INFORMATION PAGE