Attachment 1 - Bidder's Certified Statements FINAL LOCKED3.docx

ATTACHMENT 1

BIDDER’S CERTIFIED STATEMENTS

Invitation for Bids (IFB) 1195 Contracted Special Education Teacher for MacCormick Secure Center (Reissue)

MANDATORY SUBMISSION: to be completed, signed, and included in the Bid

SECTION ONE: Information Regarding the Bidder

A. Provide the Bidder’s contact information and identification numbers.

Name:

Organization:

Address:

City, State, and ZIP Code:

Telephone Number (include area code):

Email Address:

Taxpayer Identification Number:

NYS Vendor Identification Number, if available:

B. Provide the contact information of the bidder’s primary contact with OCFS regarding this bid.

Name:

Title:

Address:

City, State, and ZIP Code:

Telephone Number (include area code):

Email Address:

C. Provide the contact information of the person authorized to contractually bind the bidder, if different from (B).

Name:

Title:

Address:

City, State, and ZIP Code:

Telephone Number (include area code):

Email Address:

D.

In accordance with Section 1.2 of this IFB pursuant to the Procurement Lobbying Law, provide the name, address, telephone number, email address, place of principal employment, and occupation of any person authorized to represent the bidder. This requirement applies not only to bidder’s employees involved in the submission of the bid, but also to every individual or organization employed or designated by the bidder to attempt to influence the procurement process. If there is none, state that. This information must be updated if, after the deadline for submission of bids, the bidder retains an individual or organization to attempt to influence the procurement process. Indicate also whether the individual or organization has a financial interest in the procurement.

Name:

Title:

Address:

City, State, and ZIP Code:

Telephone Number (include area code):

Email Address:

Place of Principal Employment:

Occupation:

SECTION TWO: Minimum Qualifications (See IFB Section 3.0 for additional information)

SECTION THREE: Bidder’s Acknowledgement of Bid Requirements

* A Response of “No” to questions marked with an asterisk in Sections Two or Three will result in the disqualification of your bid.

SECTION FOUR: The bidder is (check as applicable)

|_| A New York State Certified Minority-owned Business Enterprise (MBE)

|_| A New York State Certified Women-owned Business Enterprise (WBE)

|_| A New York State Certified Minority- and Women-owned Business (MWBE)

|_| A New York State Certified Service-Disabled Veteran-Owned Business (SDVOB)

|_| A Small Business Enterprise (SBE) domiciled in New York State as defined and clarified by New York State Empire State Development – Small Business Division

|_| None of the above

SECTION FIVE: Information Regarding the Contract

Provide the contact information of the person authorized to receive notices regarding any contract resulting from this procurement.

Name:

Title:

Address:

City, State, and ZIP Code:

Telephone Number (include area code):

Email Address:

SECTION SIX: Signature Attestation (REQUIRED)

By signing below, I attest that I have express authority to sign these certified statements on behalf of the bidder and am authorized by law to bind the bidder contractually.

Signature:

Print Name:

Title:

Organization:

Date: