7-5. Exhibit-B-2023.pdf
PDF 153 KB Posted
- Solicitation number
- 202518
- Issued by
- Erie County, New York
About this file
This document is an Exhibit B Respondent Data form for a contract opportunity with ECMCC (Erie County Medical Center Corporation), located in Western New York. The form requires potential respondents to provide comprehensive details about their business, including firm name, tax ID, addresses, points of contact, business structure, ownership details, and potential conflicts of interest. The form seeks detailed information about the legal and operational status of businesses interested in submitting a proposal.
The form includes sections for respondents to disclose business relationships with hospitals and healthcare providers in Western New York, as well as certifications such as Minority Owned Business Enterprise (MBE), Women Owned Business Enterprise (WBE), and Service Disabled Veteran Owned Business Enterprise (SDVOB). Respondents are asked to check any applicable agreements like New York State OGS, GSA Federal, Sourcewell, Omnia, and Premier Inc. GPO agreements. The document also requires disclosure of any past contract terminations, current or recent employment relationships with ECMCC, and potential conflicts of interest, demonstrating a thorough vetting process for potential contractors.
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Text version
EXHIBIT B RESPONDENT DATA
To facilitate correct drawing and execution of a contract for services, respondents shall supply full information concerning legal status:
Firm Name:
Tax Payer ID:
Any trade name or assumed name (“d/b/a”):
Address of Principal office:
Street:
City: State:
Zip: Phone:
Address of Local Office:
Street:
City: State:
Zip: Phone:
Point of Contact:
Please provide a point of contact(s) for any clarifying questions for your proposal submission.
Name:
Email:
Phone Number:
Name:
Email:
Phone Number:
Check one:
☐Corporation
☐Limited Liability Company
☐Partnership
☐Individual
Formed under the laws of the state of: .
If a foreign entity, state whether authorized to do business in the State of New York:
☐Yes
☐No
Names and addresses of all directors and officers (or managers if an LLC):
Names and percentage ownership interest of all shareholders, partners, or members:
Disclose whether respondent has ever had a contract terminated and if so, provide a detailed explanation of the contract and circumstances surrounding termination.
Disclose whether any shareholder, director, officer or employee is currently employed by
ECMCC, or was an employee of ECMCC during the two (2) year period preceding the date of the proposal, and if any shareholder, director, officer or employee is a member of any governing board of ECMCC or its affiliates.
Disclose any other areas that may be a potential conflict of interest.
Describe all contracts, affiliations, referral arrangements or other business relationships the respondent has with any hospital, health care system or health care provider with offices or facilities in Western New York.
Please check any/all that apply: Certification #/Contract #
☐New York State OGS Agreement
☐GSA Federal Agreement
☐Sourcewell agreement
☐Omnia Agreement
☐Premier Inc. GPO
☐NYS Certified Minority Owned Business
Enterprise (MBE) (If so, please provide a copy of the NYS Certificate with proposal)
☐NYS Certified Women Owed Business
Enterprise (WBE) (If so, please provide a copy of the NYS Certificate with proposal)
☐NYS Certified Service Disable Veteran
Owned Business Enterprise (SDVOB) (If so, please provide a copy of the NYS Certificate with proposal)
Authorized Signature
Print Name and Title
Date
File details come from the government source that posted it. Updated .