7-5. Exhibit-B-2023.pdf
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- Attached to
- GRAPHIC DESIGN AND VISUAL CONTENT SERVICES
- Solicitation number
- 202609
- Issued by
- Erie County, New York
About this file
This is an Exhibit B Respondent Data form for a graphic design and visual content services solicitation issued by the Erie County Medical Center Corporation (ECMCC) in New York. The form serves as a standardized template for vendors to submit comprehensive organizational and operational information required to support their proposal submissions. While the document does not specify explicit response deadlines, award dates, or contract terms, it establishes the administrative framework through which qualified vendors must provide detailed information about their firm's legal structure, ownership, management, and organizational composition to facilitate contract execution and administration.
The form requires respondents to disclose their legal status, taxpayer identification, principal and local office locations, key points of contact, and complete ownership and management details. Additionally, vendors must disclose any prior contract terminations, potential conflicts of interest including current or recent employment relationships with ECMCC, and any existing business relationships with hospitals or healthcare providers in Western New York. The form includes checkboxes for vendors to certify their status as holders of New York State OGS Agreements, GSA Federal Agreements, Sourcewell agreements, Omnia Agreements, or Premier Inc. GPO contracts, as well as minority, women, and service-disabled veteran-owned business enterprise certifications, which may be relevant to any applicable set-asides or preference programs associated with this solicitation.
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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 .