7-5. Exhibit-B-2023.pdf
PDF 153 KB Posted
- Solicitation number
- 2026-02
- Issued by
- Erie County, New York
About this file
This is a Respondent Data form (Exhibit B) for the Erie County Medical Center Corporation (ECMCC) in New York State, designed to collect comprehensive information from vendors bidding on the UST Diesel Tank #13 5000 Gallon Removal & Replace project. The form requires respondents to provide complete organizational details including firm name, tax identification number, principal and local office addresses, and designated points of contact. Bidders must disclose their legal structure (corporation, LLC, partnership, or individual), state of formation, and authorization to conduct business in New York if a foreign entity. Additionally, respondents must supply names and addresses of all directors, officers, or managers, along with names and percentage ownership interests of all shareholders, partners, or members.
The form includes several critical disclosure requirements that vendors must complete to be considered for award. Respondents must disclose any prior contract terminations with detailed explanations, any current or recent employment relationships with ECMCC within the preceding two years, involvement with ECMCC governing boards, and potential conflicts of interest. Vendors are required to describe all contracts, affiliations, referral arrangements, and business relationships with hospitals, health care systems, or health care providers operating in Western New York. The form also requests certification information, including eligibility under various procurement agreements such as New York State OGS, GSA Federal, Sourcewell, Omnia, and Premier Inc. GPO contracts, as well as certification status as a Minority Owned Business Enterprise (MBE), Women Owned Business Enterprise (WBE), or Service Disabled Veteran Owned Business Enterprise (SDVOB), with copies of applicable certificates required for submission.
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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 .