Additional Information Form 3-12.doc

THIS IS A REQUEST FOR A QUOTATION ONLY.

IN ADDITION TO THE QUOTATION, PLEASE PROVIDE THE FOLLOWING INFORMATION

**General Information** Date of Quote: ________________

Company Name: ___________________________________

Contact Name: ___________________________________________________

Phone Number: ___________________ Fax Number: __________________

Contact E-mail:__________________________________________________

TIN/EIN Number: __________________ DUNS Number: _________________

Does your company have active registration in the System for Award Management (SAM)?

Yes_____ No_____ The vendor must have active registration in SAM to be eligible for an award.

**The vendor may create a new registration or update its representations through the following link—https://www.sam.gov/portal/public/SAM/** Business Status (check those that apply):

Small____ Large____ Women-Owned Small Business____ Disadvantaged____

8(a) ____ Service Disabled Veteran Owned Small Business ____ Delivery Terms:

Delivery date: ______________

FOB: _________________

(Unless otherwise specified, all shipments will be FOB Destination.)

Contract Type and Price Verification:

GSA/SEWP contract number (if applicable): _________ _________ or open market:_____ For GSA quotes, provide snapshots of the applicable items from the vendor’s GSA contract price list. For open market quotes, provide snapshots of the applicable items from the vendor’s published price list.

**Supply Information**

(IF APPLICABLE)

Identify the principal plant or place of business where the items will be produced, supplied from stock, or where the service will be performed:

_______________________ (Street Address)

_______________________ (City, State, Zip+4) Indicate whether the place of manufacture of the end product(s) is within or outside the United States: ________________

**Warranty Information**

(IF APPLICABLE)

Warranty period of coverage:_______________________________

Repairs: On-site_____ Off-site:_____ Warranty includes: Parts_____ Labor_____

Warranty information phone number and contact person: _______________________________________________________________ **Maintenance Information**

(If APPLICABLE) Period of coverage: ___________________________________

Phone number for technical support and contact person:

Other phone numbers, if applicable:____________________________ Technical support email address: _______________________________________________________

Days and hours of coverage, e.g., 24/7/365 (24 hours a day, 7 days a week, 365 days a year for technical assistance): _______________________________________________________________________

Includes (check all that apply):

___updates ___upgrades ___fixes

Site visits (indicate how many will be necessary and any travel costs that apply):

Other (provide specific information, including any additional costs):

Specify maintenance terms:

_____begins after expiration of warranty _____begins upon delivery/acceptance of product If the solicitation so authorizes, the vendor may offer items equivalent to those described therein; however, the vendor must submit specifications that demonstrate their equivalence.

The vendor may respond to this RFQ by e-mail to Stephanie.Puryear@ssa.gov.

Please direct any questions to the Purchasing Agent.