Bid Document - DMVA Statewide Pest Control.pdf

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Attached to
OAAA, 2010, Provide Statewide Pest Management Services
Solicitation number
DQ1 OAAA 2017001294 1
Issued by
Arapahoe County, Colorado

About this file

This is a Documented Quote (DQ) solicitation issued by the State of Colorado Department of Military and Veterans Affairs (DMVA) for statewide pest management services at various DMVA facilities. The solicitation requests indoor and outdoor pest management services including rodent control, insect control, snake control, wild animal control, and nuisance bird management. Services will be provided on a monthly routine basis and on-call emergency basis, with vendor response required during normal duty hours (7:30 a.m. to 4:30 p.m., Tuesday through Friday). The bid submission deadline is April 21, 2017 at 11:00 a.m. Mountain Time, with bids accepted via mail, email, or fax. The initial contract term runs from July 1, 2017 through September 30, 2017, with an extension to June 30, 2018, and options to renew for up to three additional one-year periods at the sole discretion of DMVA. Award will be made to the lowest responsive and responsible bidder on a total annual cost per location basis, with vendors able to bid one or all locations with separate costs per month per location.

Pricing must be submitted in U.S. dollars, all-inclusive of overhead, profit, travel time, benefits, and specialized equipment, with no additional charges permitted. All pricing shall be FOB Destination and valid for 60 days pending award and through the initial contract term. The successful bidder must be a licensed pest control contractor with the State of Colorado, comply with all EPA and state environmental regulations, maintain workers' compensation and general liability insurance with minimum combined single limits of $1,000,000 and aggregates of $2,000,000, and name the State of Colorado as an additional insured. The vendor must submit proof of licensure, utilize only approved pesticides from the COARNG Approved Pesticide list, complete monthly pest management maintenance reports, and comply with all federal contract provisions including nondiscrimination, environmental protection, drug-free workplace, and debarment requirements. Vendor employees must obtain passes and identification, comply with security restrictions prohibiting weapons and cell phones in restricted areas, and adhere to all OSHA and fire safety standards.

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State of Colorado

Department of Military and Veterans Affairs Purchasing and Contracts 6848 S. Revere Parkway

Centennial, CO 80112

DOCUMENTED QUOTE (DQ)

ISSUE DATE: April 14, 2017 DQ NUMBER: DQ1,OAAA,2017001294,1

DQ BID SUBMISSION DEADLINE DATE / TIME: 4/21/2017 11:00 am, MT

FAXED / EMAIL BIDS ARE ACCEPTED.

Purchasing Agent: Emiliano Barela Email: emiliano.barela@dmva.state.co.us Telephone #: (720) 250-1540 Fax #: (720) 250-1579

ALL questions regarding this solicitation must be directed to the Purchasing Agent above.

Bidders are urged to read the DQ Solicitation Document thoroughly and comply with all instructions before submitting a bid.

Documented Quote Title/Description:

Statewide Pest Management Services

Modifications:

a. Any modifications or changes to this solicitation will be published on the CO Vendor Self Service

Portal (CO VSS). It is solely the responsibility of the Bidder to monitor the CO VSS for any changes.

b. Deviation from these specifications during the bid process, or changes to the purchase order resulting from this solicitation, will not be allowed unless previously authorized, in writing only, by a modification to the solicitation or purchase order issued from the DMVA Purchasing and Contracts Office.

2. DQ Bid Submission:

a. Complete Solicitation Instructions/Term and Conditions that apply to this solicitation and subsequent award can be found on the CO Vendor Self Service Portal Documented Quote Announcement page, just above the Specifications Section.

b. Responses to this solicitation MUST be received no later than the stated DQ Bid Submission Deadline Date and Time.

c. Submission by mail, email or fax will be accepted.

d. Late bids will not be accepted.

e. All responses require the return of the entire completed DQ Form including pricing pages, signature page, W9, response to all Attachments. The DQ Pricing and Submission Form must reflect all Modifications to this DQ.

f. DQ Pricing and Submission Form must be signed by an individual with express authority to bind the bidding company.

g. The State respects the environment and desires to do business with Bidders who share this concern. The Bidder who is awarded this solicitation agrees that, wherever required, all reports, catalogs, correspondence, or other submittals will be made on recycled paper and with copying on both sides of the pages. (Recycled paper meaning not less than 50% of the total weight consisting of secondary and post-consumer waste, and not less than 10% total weight consisting of post-consumer waste.)

3. Bid Opening:

a. There is no formal opening for this DQ.

b. Results will not be given by phone or fax. For bid results, consult the award section the CO

Vendor Self Service Portal. Allow five days after bid submission date for posting of award notice.

6. Award:

a. DMVA will award this solicitation and enter into an agreement with the winning Bidder(s) through an executed DMVA Purchase Order.

b. This solicitation will be awarded to lowest responsive responsible bid of total annual cost per location . Vendors may bid one or all locations; however, each location must be bid separate with a cost per month per location for Pest Management services.

c. The initial term of the purchase order shall be 1 year. Initial term of the purchase order shall be from July 1, 2017 through September 30, 2017 with an extension to June 30, 2018, with option to renew for up to three (3) years, one (1) year at a time. Exercising the option to renew will be at the sole discretion of DMVA but will only be done upon mutual agreement between DMVA and the Vendor.

d. Awarded Vendor may request amended pricing once in each 12-month period thereafter the initial term of the contract. The awarded Vendor shall request any price increase in writing to the DMVA at least 60 days prior to the anticipated increase, and such request shall justify the increase by describing verifiable awarded Contractor cost increases. Such requests shall contain complete documentation, and cost justifications which may be based on the Producer Price Index, Consumer Price Index, or similar industry pricing guides, and increases cannot exceed 5% for any renewal period. Such price changes must be accepted by the DMVA and become effective by amendment to the Purchase Order.

e. Contractor is not authorized to begin performance without receipt of a fully executed contract, issued by the DMVA Purchasing Office and or a Notice to Proceed issued by the DMVA Project Manager.

f. Award and subsequent Purchase Order will be contingent upon funds being appropriated, budgeted, and otherwise made available.

7. Alternates: Not Applicable.

8. Bid Evaluation:

a. DMVA will be the sole judge in determining the acceptability of an offer and reserves the right to award the bid in the best interest of the State.

b. Award shall be made to the Bidder who is determined to be the lowest responsible and responsive

Bidder whose bid meets the requirements and criteria set forth in this solicitation. Award shall be subject to specification verification.

c. Low Tie Bids shall be decided in accordance with the provision of C.R.S., Section 24-103-202.5, as it currently exists or is hereafter amended, which give a preference to resident Bidders. Any Bidder who wishes to be considered a "Resident Bidder" for purposes of the tie bid procedure provided in C.R.S., Section 24-103-202.5 shall include with their bid proof that he/she meets the definition of Resident Bidder as set forth in either C.R.S., Section 24-103-101(6)(a) or C.R.S., Section 24-103-101(6)(b).

d. In accordance with Procurement Code, CRS 24-103-207.5 titled “Purchasing Preference for Environmentally Preferable Products”; Bidders responding to this solicitation may seek to qualify for the preference and governmental bodies conducting this solicitation shall award a contract to a Bidder who offers environmentally preferable products subject to the conditions in the Code and Procurement Rules.

9. Non-Responsive:

a. Failure to complete and submit all attachments and forms reflecting any and all Modifications or to follow any instructions in this solicitation will cause the bid to be considered non-responsive.

b. Exceptions taken by any Bidder may cause their bid to be considered non-responsive. The State will be sole judge of what constitutes an allowable exception, and then only if the basic requirements of the specification are essentially unaltered.

c. Any requests to change the State’s Terms and Conditions will cause the bid to be considered non-responsive.

d. By submitting a bid, Bidder agrees that DMVA reserves the right to accept or reject any alternate bids if allowed for in the solicitation.

e. Illegible responses will be rejected as non-responsive, except as provided for by the State of Colorado Fiscal Rule 4.10.

10. Failure to Render Service/Cancellation: In the event the awarded Vendor fails to deliver goods or render service as stated, the State of Colorado reserves the right to cancel this Documented Quote and any award thereof, by written notification. In the case of cancellation, the State reserves the right at its sole discretion to award to another Bidder, to re-bid the items, or to implement other solutions to assure a continued delivery of goods and/or services.

11. Doing Business in Colorado: Vendors wanting to do business in Colorado must register with the Colorado Secretary of State in accordance with Colorado Revised Statute (CRS) 7-90-801. This is the link for the Colorado Secretary of State’s website at http://www.sos.state.co.us . (Recommend going to the “Business Center” section, then opening the “Business Home” page, under the “General Information” section, review the FAQs.)

12. Insurance: The successful bidder shall procure and maintain for the duration of the project the insurance coverage’s identified below.

A. Standard Worker’s Compensation and Employer Liability.

1) As required by State Statute including occupational disease, covering all employees at the work site.

B. General Liability (PL & PD) (Minimum)

1) Combined single limit of $1,000,000, if written on an occurrence basis

2) Any aggregate limit will not be less than $2,000,000.

3) Personal & Advertising Injury not less than $1,000,000

4) Products & Completed Operations Aggregate not less than $2,000,000 C. Automobile Liability (Minimum)

1) Combined Single Limit of $1,000,000

2) Bodily Injury per Person $1,000,000

3) Bodily Injury each Accident $1,000,000

4) Property Damage Liability $1,000,000

D. Fire Damage

1) Fire Damage pays for property damage by a fire caused by the insured. The minimum amount normally provided by a CGL policy is $50,000 for any one fire.

E. The State of Colorado MUST be named as additional insured on all liability policies.

F. Insurance shall include provisions preventing cancellation without 45 days prior notice by certified mail to the State.

13. Beginning Performance: The Vendor is not authorized to begin performance without receipt of a fully executed Purchase Order and a Notice-to-Proceed from the DMVA Project Manager. If performance begins prior to the receipt of said documents, the State of Colorado will not be obligated to pay for services provided.

14. Remedies: Per Article 109 of the Colorado State Procurement Rules.

15. Federal Contract Provisions

The Contractor shall be responsible for adhering to the following Federal Contract Provisions:

1. NONDISCRIMINATION

Contractor covenants and agrees that no person shall be subject to discrimination or denied benefits in connection with the Contractor’s performance under the agreement. Accordingly, and to the extent applicable, the Contractor covenants and agrees to comply with the following national policies prohibiting discrimination:

On the basis of race, color or national origin, in Title VI of the Civil Rights Act of 1964 (42 U.S.C.

Section 2000d et seq.), as implemented by DoD regulations at 32 CFR Part 195. b. On the basis of race, color or national origin, in Executive Order 11246 as implemented by Department of Labor regulations at 41 CFR Chapter 60. c. On the basis of sex or blindness, in Title IX of the Education Amendments of 1972 (20 U.S.C. Section 1681, et seq.), as implemented by DoD regulations at 32 CFR Part 196. d. On the basis of age, in the Age Discrimination Act of 1975 (42 U.S.C. Section 6101, et seq.), as implemented by Department of Health and Human Services regulations at 45 CFR Part 90. e. On the basis of handicap, in Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794), as implemented by the Department of Justice regulations at 28 CFR part 41 and DoD regulations at 32 CFR Part 56.

2. LOBBYING RESTRICTIONS

By accepting funds under contract, Contractor agrees that none of the funds obligated on the contract shall be expended, directly or indirectly, to pay any person for influencing or attempting to influence an officer or employee of any agency, or a Member of Congress in connection with any of the following covered federal actions.

The awarding of any federal contract; the making of any federal grant; the making of any federal loan; the entering into, extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or Cooperative Agreement.

The Final Rule, New Restrictions on Lobbying, issued by the Office of Management and Budget and the Department of Defense (32 CFR Part 28) to implement the provisions of Section 319 of Public Law 101- 121 (31 U.S.C. Section 1352) is incorporated by reference and the Contractor agrees to comply with all the provisions thereof, including any amendments to the Interim Final Rule that may hereafter be issued.

3. DRUG-FREE WORK PLACE

The Contractor covenants and agrees to comply with the requirements regarding drug-free workplace requirements in 32 CFR Part 26, which implements Section 5151-5160 of the Drug-Free Workplace act of 1988 (Public Law 100-690, Title V, Subtitle D; 41 U.S.C. 701, et seq.).

4. ENVIRONMENTAL PROTECTION

The Contractor covenants and agrees that its performance under this Agreement shall comply with:

1) The requirements of Section 114 of the Clean Air Act (42 U.S.C. Section 7414);

2) Section 308 of the Federal Water Pollution Control Act (33 U.S.C. Section 1318), that relates generally to inspection, monitoring, entry reports, and information, and with all regulations and guidelines issued thereunder;

3) The Resources Conservation and Recovery Act (RCRA); 4) The Comprehensive Environmental Response, Compensation and Liabilities Act (CERCLA); 5) The National Environmental Policy Act (NEPA); 6) The Solid Waste Disposal Act (SWDA); 7) The applicable provisions of the Clean Air Act (42 U.S.C. 7401, et seq.) and Clean Water Act (33 U.S.C. 1251, et seq.), as implemented by Executive Order 11738 and Environmental Protection Agency (EPA) rules at 40 CFR Part 31; 8) To identify any impact this award may have on the quality of the human environment and provide help as needed to comply with the National Environmental Policy Act (NEPA, at 42 U.S.C. 4321, et seq.) and any applicable federal, state or local environmental regulation.

In accordance with the EPA rules, the Contract further agrees that the Contractor shall also identify to DMVA any impact this award may have on:

1) The quality of the human environment, and provide help that DMVA may need to comply with the National Environmental Policy Act (NEPA, at 42 U.S.C. 4321, et seq.) and to prepare Environmental Impact Statements or other required environmental documentation. In such cases, the recipient agrees to take no action that will have an adverse environmental impact (e.g., physical disturbance of a site such as break ground) until the DMVA provides written notification of compliance with the environmental impact analysis process. 2) Flood-prone areas, and provide help that DMVA may need to comply with the National Flood Insurance Act of 1968 and Flood Disaster Protection Act of 1973 (42 U.S.C. 4001, et seq.), which require flood insurance, when available, for federally assisted construction or acquisition in flood prone areas. 3) Coastal zones, and provide help that DMVA may need to comply with the Coastal Zone Management Act of 1972 (16 U.S.C. 1451, et seq.), concerning protection of U.S. coastal resources.

4) Coastal barriers, and provide help that DMVA may need to comply with the Coastal Barriers Resource Act (16 U.S.C. 3501 et seq.), concerning preservation of barrier resources. 5) Any existing or proposed component of the National Wild and Scenic Rivers System, and provide help that DMVA may need to comply with the Wild and Scenic Rivers Act of 1968 (16 U.S.C. 1271 et seq.). 6) Underground sources of drinking water in areas that have an aquifer that is the sole or principal drinking water source, and proved help that DMVA may need to comply with the Safe Drinking Water Act (42 U.S.C. 300H-3).

5. DEBARMENT AND SUSPENSION

Contractors are subject to the non-procurement debarment and suspension regulations implementing Executive Order 12549 and 12689, 2 CFR part 180. These regulations restrict awards, sub-awards, and contracts with certain parties that are debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance programs or activities. DMVA is required to comply with the DOD implementation of 2 CFR Part 180 (at 2 CFR Part 1125) by checking the Excluded Parties List System (EPLS) at www.sam.gov to verify contractor eligibility to receive contracts and subcontracts resulting from this Agreement. The DMVA and sub-recipients shall not solicit offers from, nor award contracts to contractors listed in EPLS. This verification shall be documented in the DMVA and sub-recipient contract files, and shall be subject to audit by the Federal Program and Federal/State audit agencies.

6. BUY AMERICAN ACT

Contractor covenants and agrees to comply with the Buy American Act (41 U.S.C. 10a et seq.). The Buy American Act gives preference to domestic end products and domestic construction material. In addition, the Memorandum of Understanding between the United States of American and the European Economic Community (EEC) on Government Procurement, and the North American Free Trade Agreement (NAFTA), provide that EEC and NAFTA end products and construction materials are exempted from application of the Buy American Act.

7. UNIFORM RELOCATION ASSISTANCE AND REAL PROPERTY ACQUISITION POLICIES

Contractor covenants and agrees to comply with CFR 49 part 24, which implements the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (42 U.S.C. Section 4601 et seq.) and provides for fair and equitable treatment of persons displaced by federally assisted programs or persons whose property is acquired as a result of such programs.

8. COPELAND “ANTI-KICKBACK” ACT

Contractor covenants and agrees to comply with the Copeland “Anti-Kickback” Act (18 U.S.C. Section

874) as supplemented in Department of Labor regulations (29 CFR Part 3). As applied to this agreement, the Copeland “Anti-Kickback” Act makes it unlawful to induce, by force, intimidation, threat of procuring dismissal from employment, or otherwise, any person employed in the construction or repair of public buildings or public works, financed in whole or in part by the United States, to give up any part of the compensation to which that person is entitled under a contract of employment.

9. CONTRACT WORK HOURS AND SAFETY STANDARDS ACT

Contractor covenants agrees to comply with Sections 103 and 107 of the Contract Work Hours and Safety Standards Act (40 U.S.C. Sections 3701-3708) as supplemented by Department of Labor regulations (29 CFR Part 5). As applied to this agreement, the Contract Work Hours and Safety Standards Act specifies that no laborer or mechanic doing any part of the work contemplated by this agreement shall be required or permitted to work more than 40 hours in any workweek unless paid for all additional hours at not less than 1.5 times the basic rate of pay.

10. SCOPE OF WORK – STATEWIDE PEST MANAGEMENT SERVICES

Vendor to provide indoor and outdoor Pest Management services at various DMVA Facilities for the elimination and proper removal of animals, unwanted rodents and insects.

Pest Management includes, but is not limited to:

Mice/Rodent control Insect control (Cockroaches, Ants, Spiders Bees and Wasps only when required) (Termite and

Mosquito control not required) Snake control (including poisonous snakes such as Rattlesnakes) Wild animal control (Primarily Skunks, Bats, Raccoons, Foxes and Prairie Dogs) Nuisance Birds (such as Woodpeckers) For miscellaneous vertebrate pests such as dogs, cats, skunks, raccoons, squirrels and such, use live trapping with wire or solid cage traps. Release wild animals in remote areas as permitted by law or regulation. Cats and dogs shall be taken to local animal shelters. Prairie dogs shall also be live trapped and relocated wherever possible and if live trapping proves ineffective, the Department of Military and Veterans Affairs (DMVA) State Maintenance Supervisor shall be contacted to discuss possible control with pesticides.

Mice and rats may be controlled with any sticky trap, mechanical traps, or Bromodialone .0005% if mechanical or sticky traps prove ineffective. Special care shall be taken in areas with endangered bird species.

FREQUENCY

The services will be required on a monthly, an on-call routine, and an on-call Emergency basis.

The Vendor shall respond to service calls placed by authorized DMVA personnel during normal duty hours; 7:30 a.m. to 4:30 p.m. Tuesday through Friday. Service calls may be classified as emergency or routine. The assigned designation will be given to the contractor by the authorized DMVA staff member, the Vendor is expected to respond accordingly.

Facilities are open Tuesday through Friday 6:30 AM – 5:00 PM except for the following holidays:

Tuesday, July 4, 2017 Independence Day Friday, September 1, 2017 Labor Day Friday, October 6, 2017 Columbus Day Friday, November 10, 2017 Veterans Day Thursday, November 24, 2017 Thanksgiving Day (Workweek Change: Mon-Weds) Friday, December 22, 2017 (Observance) Christmas Day

Friday, December 29, 2017 (Observance) New Year's Day 2018 Friday, January 12, 2018 (Observance) Martin Luther King Day

Friday, February 16, 2018 (Observance) Presidents Day Friday, May 25 2018 (Observance) Memorial Day

GENERAL INFORMATION

Vendor Employees Qualifications. Vendor must be a licensed pest control contractor with the State of Colorado and required to follow all EPA and State Environmental rules and laws.

Vendor shall submit proof of (copy of license) with this documented quote.

Any pesticide used for control must be on the approved COARNG Approved Pesticide list (attached), and all application guidelines must be strictly adhered to.

Vendor is required to record pest surveillance and control on the Pest Management Maintenance Record DD form 1532-1 (attached). A copy of MSDS and pesticide applicator certification cards will be provided to and kept on file by the Facilities Maintenance Supervisor.

Vendor shall submit to the DMVA representative monthly reports showing types, amounts and locations of substances and procedures used for that month.

SECURITY REQUIREMENTS

Vendor employees shall not take or use cell phones and or photography devices in any restricted areas.

Pass and Identification Items. The contractor shall ensure all pass and identification items required for contract performance are obtained for non-Government owned company vehicles each and every time of entry, i.e. valid registration, insurance, and driver license.

Random Personnel and Vehicle Searches. Vendor personnel are subject to random personal and vehicle searches. If Vendor personnel refuse to be searched, they will be denied entry to the facility.

Weapons, Firearms, and Ammunition. Vendor employees are prohibited from possessing weapons, firearms, or ammunition, on themselves or within their Vendor owned vehicle or privately owned vehicle while working at DMVA/COARNG Facilities.

Reporting Requirements. Vendor personnel shall immediately report to an appropriate Government authority any information or circumstances of which they are aware may pose a threat to the security of DMVA personnel, Vendor personnel, resources, and classified or unclassified defense information.

Physical Security. Vendor employees shall be responsible for safeguarding all Government property and controlled forms provided for Vendor use. At the end of each work period, all Government facilities, equipment, and materials shall be secured.

SAFETY

The Vendor shall comply with all applicable laws and safety regulations. Compliance with Occupational Safety and Health Act (OSHA) and other applicable laws and regulations for the protection of employees is exclusively the obligation of the contractor, and the DMVA will assume no liability or responsibility for the contractor’s compliance or noncompliance with such responsibilities.

The Vendor is responsible for providing Vendor employees with all necessary safety equipment and clothing. The Vendor shall have MSDS on hand for all chemicals along with ensuring that all containers are labeled.

Vendor shall comply with all Local, State, and Federal Government Environmental regulations.

Fire Prevention and Safety Standards. Vendor employees shall comply with OSHA and the Fire

Prevention and Health Program.

Work Area. The Vendor shall, at all times, keep work areas free from accumulations of waste material, rubbish, tools, scaffolding, equipment, and materials. Upon completion of the job or when away from the work site, the Vendor shall leave the work area and premises in a clean, neat, safe and workmanlike condition. The Vendor is responsible for removal and proper disposal of all job related waste material at a permitted site.

Smoking in Facilities. Vendor is advised that the DMVA/COARNG has placed restrictions on the smoking of tobacco products in facilities. Vendor employees and visitors are subject to the same restrictions as Government personnel. Smoking is permitted only in designated smoking areas.

Illegal Substances. Illegal substance possession and/or use will not be tolerated at State Facilities.

The Vendor shall ensure that Vendor employees who have access do not possess and/or use illegal substances. All Vendor and subcontractors are required to adhere to all federal laws concerning possession and/or use of illegal substances. Any Vendor staff found to be in possession of illegal substances will be barred from State Facilities and subject to prosecution by authorities. Although the State of Colorado permits the use of marijuana, it is an illegal substance at all State Facilities.

17. Firm Pricing:

a. Pricing must be valid for 60 days pending award and then through the initial term of the award.

b. Pricing to be submitted in the specified Unit of Measure, i.e. $ price per month.

c. All pricing submitted for bid evaluation must be rounded up or down to the nearest whole cent.

Prices shall not exceed two decimal places (example $5.32). All pricing on the invoice must be in line with the bid price and may not exceed two decimal places.

d. Pricing must be all-inclusive. The all-inclusive rates shall include; overhead, profit, travel time, benefits, use of specialized traps, chemicals, etc. No extra charges will be allowed.

e. Pricing must be submitted in U. S. Dollars.

f. All pricing shall be FOB Destination.

18. Bidder Location / Pricing Schedule is attached

19. Vendor Information and Signature: All information must be supplied.

The Department of Military and Veterans Affairs has issued this solicitation to establish a price agreement and rates for the good or services listed between the Contractor and the State of Colorado, on behalf of State Agencies, Institutions of Higher Education, Political Subdivisions, eligible Non-Profits and other entities (including cooperatives), pursuant to the terms of this solicitation and the resulting price agreement.

By your signature, you are verifying that you have read and accepted this solicitation in its entirety, that you are expressly authorized to sign, and that you agree to provide the goods and/or services as outlined in this solicitation in accordance with the State of Colorado Terms and Conditions and any special provisions as published on CO Vendor Self Service Portal.

Vendor Name: By (Print Name):

Business Address: Title:

City, State, Zip: Signature:

Mail POs To Address: Date:

City, State, Zip: FEIN or SS#:

Remittance Address:

City, State, Zip: E-mail: _______________________________________________

Fax: _________________________________________________ Telephone:

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