7-5. Exhibit-B-2023.pdf
PDF 153 KB Posted
- Attached to
- GIFT CARD PROGRAM FOR GRANT PURPOSES
- Solicitation number
- 202521
- Issued by
- Erie County, New York
About this file
Exhibit B is a respondent data form required by Erie County Medical Center Corporation (ECMCC) in New York for vendors responding to a proposal solicitation for a gift card program to support procurement of goods and services for Federal and State grant-funded programs. The form requires respondents to provide comprehensive organizational information including legal entity status, principal and local office addresses, points of contact, and details regarding corporate structure such as directors, officers, managers, and ownership interests. Respondents must disclose any prior contract terminations with detailed explanations, identify any current or former employment relationships with ECMCC within the preceding two years, and disclose any potential conflicts of interest or business relationships with hospitals, health care systems, or health care providers operating in Western New York.
The form requires respondents to certify their eligibility status by indicating applicable certifications and agreements such as New York State OGS Agreements, GSA Federal Agreements, Sourcewell agreements, or Omnia Agreements. Additionally, respondents must identify whether they hold New York State certifications as Minority Owned Business Enterprises (MBE), Women Owned Business Enterprises (WBE), or Service Disabled Veteran Owned Business Enterprises (SDVOB), with copies of relevant certificates to be submitted with the proposal. The form must be completed and signed by an authorized representative with printed name, title, and date to be considered a valid 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 .