ATTACHMENT 4 COVER FORM.docx

ATTACHMENT 4 – COVER FORM

ITN Number

(M) Attachment 4, Cover Form must be completed, signed, and submitted with your Proposal. Failure to complete and submit this form may result in your Proposal being deemed non-responsive.

Instructions: The Technical Proposal must include a signed copy of this cover form. Copy and paste this form onto your company letterhead, or include the following information: Offeror’s company name, mailing address, phone number, fax number, e-mail address, and name of Offeror’s authorized signer. The cover form must include the ITN Number and Title and must be signed by an individual authorized to commit the Offeror to the contents of the Proposal.

☐ Limited Liability Corporation (LLC) ☐ Limited Liability Partnership ☐Sole Proprietorship ☐ Other (specify)

Offeror’s Tax Identification Number

EIN:

Offeror’s DUNS Number

DUNS:

Is Offeror a legal entity with the legal right to contract?

☐ Yes ☐ No

Other than modifications/exceptions identified on Attachment 3, in compliance with Section 2.4 of this ITN, does Offeror accept, and is Offeror willing to comply with, the requirements of this ITN and attachments, including but not limited to those identified in Section 1.4 and the Special Terms and Conditions in Appendix?

☐ Yes ☐ No

Is Offeror in compliance with applicable equal employment regulations?

☐ Yes ☐ No

Does Offeror affirm that it has not employed any company or person other than a bonafide employee working solely for the Offeror or a company regularly employed as its marketing agent, to solicit or secure the Contract, and that it has not paid or agreed to pay any company or person, other than a bonafide employee working solely for the Offeror or a company regularly employed by the Offeror as its marketing agent, any fee, commission, percentage, brokerage fee, gifts, or any other consideration contingent upon or resulting from the award of the Contract.?

☐ Yes ☐ No

Does Offeror understand and agree that for breach or violation of the above term, the State has the right to annul the Contract without liability or, in its discretion, to deduct from the offered price the amount of any such fee, commission, percentage, brokerage fee, gifts, or contingencies.

☐ Yes ☐ No

Firm(s) and/or staff responsible for writing the Proposal

Names:

Does Offeror affirm that it is not currently suspended, debarred, or otherwise excluded from federal or state procurement and non-procurement programs?

Note: vendor information is available at https://sam.gov.

☐ Yes ☐ No

Does the Offeror affirm that the Proposal will be firm and binding for ninety (90) calendar days from the Proposal opening date?

☐ Yes ☐ No

Does Offeror warrant that it does not knowingly and willfully employ persons who cannot legally work in this country; and that Offeror takes steps to verify that it does not hire persons who have entered our nation illegally or cannot legally work in the United States; and that any misrepresentation in this regard or any employment of persons who have entered our nation illegally or cannot legally work in the United States constitutes a material breach and will be cause for the imposition of monetary penalties up to five percent (5%) of the Contract price, per violation, and/or termination of the Contract?

☐ Yes ☐ No

Signed By:

Printed Name:

Date: