Attachment 3 - Quote Submission Form.pdf

United States Department of Agriculture

Research, Education, and Economics Agricultural Research Service

Office of the Director 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 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.

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

The Total Quoted Price is the sum of all Line-Item Total Amounts.

Line Item

Item Description Quantity Unit Unit Price Total Amount

0001 Oxygen/Carbon Dioxide Gas Analyzer Each 0002 Shipping/Freight/Delivery Each

Total Quoted Price:

Time to Delivery: ( ) days ( ) weeks ( ) months

Country of Manufacture Information:

Product Name(s) and Part Number(s):

Manufacturer’s Legal Name:

Product is Manufactured in the United States of America (is a domestic product): ( )Yes ( )No

Manufacturing Address (for domestic products):

Agricultural Research Service

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

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

Country of Origin (for nondomestic products):

( ) I confirm that a written certification of the above information was obtained from the product’s manufacturer and is included in the support documents submitted with this quote.

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:

Title:

Contact Information:

Date: