Bidder_Declaration_DFW1082ext.pdf

State of California – Department of Fish and Wildlife

BIDDER DECLARATION

DFW 1082 (REV. 05/15/23)

1. Primebidder information:

a. What is your California vendor’s name?

b. Identify your current California Certification(s) number(s):

(MB/SB/DVBE): _____________ or None (If “None”, proceed to number 2)

c. Will subcontractors be used for this contract? YES NO (If yes, indicate in the space below the distinct element of work your business will perform in this contract. If no, skip to the certification at the bottom of this page.)

2. If subcontractors will be used, list all subcontractors for this contract in the table below. (Attach additional pages if necessary):

EXAMPLE

Subcontractor Name, Contact Person, Phone Number & Email

Fix it Now John Smith Jr.

(916) 445-1234

JSmithJr@fixitnow.com

Subcontractor complete address

1234 Fix It Pl.

Sacramento, CA

95821

CA Certification Number (MB, SB, DVBE, or None)

SB # 15245

Work performed or good provided for this contract

Office repairs

Corresponding % of bid price 25%

CERTIFICATION: By signing this form (Bidder Declaration), I certify under penalty of perjury that the information provided is true and correct.

With accordance to California Civil Code §1633.5(b), I acknowledge that by providing my electronic signature for this form, I agree that my electronic signature is legal binding equivalent to a handwriting signature. I hereby confirm that my electronic signature represents my execution or authentication of this form, and my intent to be bound by it.

Authorizer’s printed name: _______________________________________ Date: ______________

Authorizer’s signature: ____________________________________________ https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fleginfo.legislature.ca.gov%2Ffaces%2Fcodes_displaySection.xhtml%3FsectionNum%3D1633.5%26lawCode%3DCIV&data=05%7C01%7CLucia.Rodriguez%40wildlife.ca.gov%7Cf7d61fe8902f4fc2ddc908db44de0a8a%7C4b633c25efbf40069f1507442ba7aa0b%7C0%7C0%7C638179492686187568%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=SgmSIctaufa78R%2BCFlJqmUDsiiE%2FYw%2FCR%2BZhi4%2BcxQ0%3D&reserved=0