Additional Information Sheet.doc

THIS IS A REQUEST FOR A QUOTATION ONLY.

IN ADDITION TO THE QUOTATION, PLEASE PROVIDE THE FOLLOWING INFORMATION

**General Information**

Company Name: ___________________________________

Contact Name: ___________________________________________________

Phone Number: ___________________ Fax Number: __________________

Contact E-mail:__________________________________________________

TIN/EIN Number: __________________ DUNS Number: _________________

Are you registered on SAM? Yes_____ No_____; SSA must verify this using your DUNS number, so please be sure to complete that field above. A vendor must be registered in SAM to be eligible to receive an award.

Business: (please check applicable categories)

Small____ Large____ Women-owned____ Disadvantaged____

8(a) ____ Service disabled/Veteran-owned small business ____ GSA/SEWP Contract Number: ___________________

(Include a copy of your GSA price list with your quote. In case of NASA SEWP, you do not need to provide a copy of your price list.)

**Maintenance Information**

Period of coverage: ___________________________________

Phone number for Technical Support (and contact person if applicable): _______________________________________________________

Website address for Technical Support, if applicable: __________________ Days and hours of coverage: i.e. 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

You may respond to this RFQ by e-mail to Roger.Twigg@ssa.gov or facsimile to the attention of Roger Twigg at: 410-966-5982.

Direct any questions to Roger Twigg at 410-965-6820.