7-5. Exhibit-B-2023.pdf
PDF 153 KB Posted
- Attached to
- IN-PERSON AND WRITTEN INTERPRETATIVE SERVICES
- Solicitation number
- 202601
- Issued by
- Erie County, New York
About this file
Exhibit B is a respondent data form for Erie County Medical Center Corporation (ECMCC) in New York, which is soliciting proposals for in-person and written interpretative services. The form requires vendors to provide comprehensive organizational information including firm name, tax payer identification, business addresses, points of contact, and legal entity classification (corporation, LLC, partnership, or individual). Respondents must disclose all directors, officers, managers, shareholders, partners, or members along with their ownership percentages, and confirm whether they are authorized to conduct business in New York if operating as a foreign entity.
The form mandates disclosure of any prior contract terminations with detailed explanations, potential conflicts of interest involving current or former ECMCC employees, and any business relationships with hospitals or healthcare systems in Western New York. Vendors must also certify relevant contractual authorities and qualifications, including New York State OGS agreements, GSA Federal agreements, and Sourcewell or Omnia partnerships. The form requests documentation of New York State certifications for Minority Owned Business Enterprises (MBE), Women Owned Business Enterprises (WBE), and Service Disabled Veteran Owned Businesses (SDVOB), with copies of applicable certificates to be submitted with the proposal. All submissions require authorized signature, printed name, title, and date of 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 .