Attachment 1 - Quote Submission Form (QSF).pdf

United States Department of Agriculture

Research, Education, and Economics Agricultural Research Service

Office of the Director ● Supply 1 Section Contracting Operations Branch ● Acquisition and Property Division

5601 Sunnyside Avenue ● Beltsville, MD 20705 USDA is an Equal Opportunity Provider and Employer

QUOTE SUBMISSION FORM

Solicitation Title: _____________________________________________________________________

Solicitation Number: ______________________

Company Information:

Currently Registered and Active in the System for Award Management (SAM): ( ) Yes ( ) No

SAM Unique Entity Identifier (UEI) Number:

Company Legal Name: _____________________________________________

Doing Business As (if applicable): ____________________________________

Company Address as registered in the System for Award Management (SAM):

CAGE Code(s):

Socio-economic status for the NAICS code: __________ (with a small business threshold of under ______________) – please check ALL that apply:

( ) Small Business Concern [ ] Disadvantaged

[ ] SBA-certified 8(a) Program Participant [ ] SBA-certified HUB Zone Business

[ ] Veteran Owned [ ] Service-Disabled Veteran Owned

[ ] Woman-Owned [ ] Economically Disadvantaged Woman Owned

( ) Other Than Small Business Concern

( ) I confirm that my company is registered in the System for Award Management (SAM) with the socio-economic status identified above and the NAICS code specified or that my firm qualifies for the selected the socio-economic status under the applicable NAICS code.

Agricultural Research Service

Office of the Director ● Supply 1 Section Contracting Operations Branch ● Acquisition and Property Division

5601 Sunnyside Avenue ● Beltsville, MD 20705 USDA is an Equal Opportunity Provider and Employer

Quote Information:

Quote Number: _________________

Quote Date:

Quote Expiration Date:

Quoted Prices:

Vendors shall insert pricing/data in the cells below. All line items must be priced.

Line Item Total Amount is the Quantity multiplied by the Unit Price.

Line Item

Item Description Quantity Unit Unit Price Total Amount

0001 On-site Maintenance and Support for FACSMelody (no lasers), Customer material#: 661762, Serial#: P6617620020

12 MO

0002 On-site Maintenance and Support for PIC Mini 405-45 Violet Laser, Customer material#: 661963, Serial#: NO-SERIAL- 10917

12 MO

On-site Maintenance and Support for PIC Mini 488-20 Blue Laser, Customer material#: 661964, Serial#: NO-SERIAL- 10918

On-site Maintenance and Support for PIC Mini 640-45 Red Laser, Customer material#: 661965, Serial#: NO-SERIAL- 10919

Please add all "Line Item Total Amounts" together for the Total Quoted Price:

Certification:

I understand that incomplete sections, failure to provide all required documentation, and/or failure to sign this certification may remove my company’s quote from being put into consideration by the Government for award.

Signature:

Name:

Agricultural Research Service

Office of the Director ● Supply 1 Section Contracting Operations Branch ● Acquisition and Property Division

5601 Sunnyside Avenue ● Beltsville, MD 20705 USDA is an Equal Opportunity Provider and Employer

Title:

Contact Information:

Date: