7-5. Exhibit-B-2023.pdf
PDF 153 KB Posted
- Attached to
- INTERNET PROTOCOL (IP) BROKERAGE
- Solicitation number
- 202608
- Issued by
- Erie County, New York
About this file
This is a Respondent Data form (Exhibit B) for a proposal submission to Erie County Medical Center Corporation (ECMCC) in New York related to Internet Protocol (IP) brokerage services. The form requires respondents to provide comprehensive organizational information including firm name, tax payer identification, principal and local office addresses, and designated points of contact for proposal clarifications. Respondents must disclose their legal structure, state of formation, and authorization to conduct business in New York, along with complete details regarding directors, officers, managers, shareholders, partners, or members and their respective ownership percentages.
The form mandates disclosure of any prior contract terminations with detailed explanations, conflicts of interest involving current or former ECMCC employees or board members, and all existing business relationships with hospitals, health care systems, or health care providers operating in Western New York. Respondents must identify applicable certifications and agreements, including New York State OGS Agreements, GSA Federal Agreements, Sourcewell agreements, Omnia agreements, and Premier Inc. GPO contracts. The form further requires documentation of New York State certifications for Minority Owned Business Enterprises (MBE), Women Owned Business Enterprises (WBE), and Service Disabled Veteran Owned Business Enterprises (SDVOB), with copies of certificates to be included with the proposal submission. All submissions must be authorized with a signature, printed name, title, and date.
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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 .