7-5. Exhibit-B-2023.pdf
PDF 153 KB Posted
- Attached to
- CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)/ BILEVEL POSITIVE AIRWAY PRESSURE (BIPAP) EQUIPMENT
- Solicitation number
- 202522
- Issued by
- Erie County, New York
About this file
Exhibit B is a respondent data form for Erie County Medical Center Corporation (ECMCC), a New York State entity, seeking proposals from qualified vendors to provide CPAP and BiPAP devices with accessories including tubing, filters, humidifiers, and compatible stands. The initial order consists of ten devices with potential for additional purchases during the contract period. The form requires respondents to provide comprehensive company information including legal status, principal and local office addresses, points of contact, corporate structure, and ownership details to facilitate correct drawing and execution of the service contract.
The respondent data form requires disclosure of prior contract terminations, potential conflicts of interest including current or recent employment relationships with ECMCC, and all business relationships with hospitals and health care systems in Western New York. Respondents must identify applicable certifications and agreements, including New York State OGS Agreements, GSA Federal Agreements, Sourcewell or Omnia agreements, and minority or women-owned business enterprise (MBE/WBE) or service-disabled veteran-owned business enterprise (SDVOB) certifications, with supporting documentation required for applicable designations. The form requires authorized signature, printed name, title, and date from the respondent to complete the 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 .