Affirmation___Disclosure.pdf

This document is an Affirmation and Disclosure Form for a contractor, which requires detailed information about the contractor's business locations and service performance sites. The contractor's principal business location is listed at 16255 CR 178 in Tyler, TX 75703, and the location where services will be performed is 26518 Barnacle, Uniontown Rd. in St. Clairsville, OH 43150. No subcontractors are indicated on the form, with "N/A" entered in those sections.

The form establishes contractual terms requiring the contractor to perform services only within the United States and mandates immediate disclosure to the state of any changes in service locations. The document requires the contractor to affirm that state data will be maintained within the United States and that they will notify the state immediately of any location shifts. The form was signed by Greg Bertaut, Vice President/General Manager, on 9/11/23, indicating the contractor's agreement to these terms and conditions for potential state contract engagement.