Bid Intent. Waiver.pdf

DEPARTMENT OF CORRECTION

REQUEST FOR RESPONSE

SBCC Integrated Security System (ISS)

RFR # 27-DOC-1000-ISS

BID INTENT SUMMARY FORM

Must be completed and emailed to Tiffany Myers:

tiffany.myers@doc.state.ma.us no later than

October 30th, 2026 by 2:00 PM EST

Attention: Tiffany Myers E-mail: tiffany.myers@doc.state.ma.us Contracts Unit, 50 Maple Street, Milford, MA 01757

RFR#: 27-DOC-100-ISS Date:________________________ We have received a copy of the RFR and plan to attend the bidder’s conference and/or site visit for this procurement. We are providing the following for clearance approval, as required.

***Note: Some states use your Social Security Number as a Driver’s License Number. If this is the case, you are requested to volunteer this information to be used solely as an aid in the investigation process.

The following information is on the employee(s) who will be attending:

Add as many rows as necessary or use an additional page:

Employee Name DOB Driver’s License Number State Background Info Attached

YES

YES

YES

YES

YES

YES

Company Name:

Individual Completing Form Signature

Street City State Zip Code

Telephone Number Fax Number

IMPORTANT NOTE: The interested bidder must also submit the “BACKGROUND INFORMATION REQUEST AND WAIVER” form, (page 2 of this document), for each employee listed above.

**Please Note: The following items are not allowed to be worn by any visitor when entering a Massachusetts Correctional Facility: No jeans, no logo shirts, no hoodies. No cell phones are allowed in the facilities.

The Department takes no responsibility for documents that were not successfully received by the Department.

DEPARTMENT OF CORRECTION

REQUEST FOR RESPONSE

SBCC Integrated Security System (ISS)

RFR # 27-DOC-1000-ISS

BACKGROUND INFORMATION REQUEST and WAIVER Must be received no later than 2:00 PM, October 30th, 2026.

Institution / Division: Date:

Contract Employee:

PERSONAL DATA

(PLEASE PRINT CLEARLY OR TYPE)

Name: , , Last First Initial

Previous Name and/or alias:

Residential Address:

(not a PO Box Number) Number Street City State Zip

Have you ever resided in another state? If “YES”, Which state(s)?

* NOTE: SOME STATES USE YOUR SOCIAL SECURITY NUMBER AS A DRIVER’S LICENSE NUMBER. IF THIS IS THE CASE, YOU ARE REQUESTED TO VOLUNTEER THIS INFORMATION TO BE USED SOLELY AS AN AID IN THE INVESTIGATION PROCESS.

Enter current Driver’s License Number (voluntary):

Your Current Driver’s License is issued from which state?

Date of Birth: / / Place of Birth:

MM DD YYYY

Mother’s Maiden Name:

Fathers Name:

I, _____________________________________________________, hereby release, discharge, and exonerate the Massachusetts Department of Correction, its agents and representatives, and any person so furnishing information, for any and all liability of every nature and kind arising out of the furnishing or inspection of documents, records and other information related to any background investigation of me that is conducted by or on behalf of the Department of Correction.

I further understand that the Department of Correction will conduct a background investigation that will include a criminal records check with the local police department, the State Police, the FBI in Washington, D.C., the Massachusetts Board of Probation, and the Registry of Motor Vehicles.

* You are requested to volunteer your Social Security Number at the right to aid in this background investigation

Signature:

CRIMINAL RECORD CHECK ONLY

**Please Note: The following items are not allowed to be worn by any visitor when entering a Massachusetts Correctional Facility: No jeans, no logo shirts, no hoodies. No cell phones are allowed in the facilities.

The Department takes no responsibility for documents that were not successfully received by the Department.