6-ITB-04-Authorized Signature and Questionnaire.pdf

CITY OF FORT WORTH - PURCHASING DIVISION

AUTHORIZED SIGNATURE AND QUESTIONNAIRE

ITB Ref. #: 26-0056 Doc. Ref#: ITB-04 Page 1 of 3 ITB Title: Brine Machine, Salt Supply, and Tank

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

D/B/A Name of Bidder:

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 bid 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 ITB and agrees to be bound by the terms therein.

The undersigned agrees if the bid 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 ITB.

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:

ITB Ref. #: 26-0056 Doc. Ref#: ITB-04 Page 2 of 3

Please answer each question below thoroughly. Responses to the questions will be used to assess the bid’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 ITB-01, Section 14.7.

Pages with information believed to be Proprietary

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

7.0 Do all items being provided meet the specifications listed in Section 2.0 of ITB-03-Specifications? Yes__ No__ If not, please explain why.

ITB Ref. #: 26-0056 Doc. Ref#: ITB-04 Page 3 of 3

8.0 Do you agree with the warranty stated in Section 3.0 of ITB-03-

Specifications? Yes__ No__ If not, please provide the warranty your company offers.

9.0 What is the expected delivery timeframe once an order has been placed?

10.0 Is your company registered in the SAM.gov database? Yes__ No__

11.0 Can you successfully deliver the items to the locations listed in section 2.5 of ITB-03-Specifications? Yes__ No__ If not, please explain why.