Attachment A.docx

Attachment A - Contractor's Response Form Intent to Sole Source

Capabilities and Information for Zeiss LSM 710 Confocal Microscope (Preventive Maintenance)

Please fully complete each section of the form below.

Company Name: Company Address: DUNS Number: Point of Contact: Phone Number: Email Address:

(1) Is your company considered small under the NAICS code?

(2) Are you the manufacturer or distributor? What is the manufacturing country of origin of these items? If not the primary, are you authorized by the manufacturer to perform the services? ______

(3) If you’re a small business and you are an authorized vendor, distributor/reseller for the items identified in Attachment B (or equivalent product/solution), do you alter; assemble; modify; the items requested in any way? If you do, state how and what is altered; assembled; modified?

(4) Does your company have an FSS contract with GSA or the NAC or are you a contract holder with NASA SEWP or any other federal contract (e-CAT, etc.)? If so, please provide the contract type and number.

(5) If you are an FSS GSA/NAC, e-CAT or NASA SEWP contract holder or other federal contract holder, are all the referenced items/solutions available on your schedule/contract and what is the contract number?

Socio-economic Classification in Accordance with NAICS code 811219 Other Electronic and Precision Equipment Repair and Maintenance (check all that apply)

· Small Business

· Service-Disabled Veteran Owned Small Business (SDVOSB)

· Verified SDVOSB by www.vip.vetbiz.gov

· Veteran Owned Small Business (VOSB)

· Verified VOSB by www.vip.vetbiz.gov

· Small Disadvantage Business

· Women-owned Small Business

· Economically Disadvantaged Small Business

· HUBZone

· 8(a) Certified

· Other:

Detailed Information:

1. What percentage of the contracted services can your company complete as the prime contractor? %

2. What percentage of the contracted services would your company subcontract?

3. Please attach your Company’s Capability Statement (1-2 pages maximum).