Bidder_Declaration.pdf

908 KB Posted

Attached to
RFQ-24-004 - Immersion Vaccines
Solicitation number
0000031837
Issued by
California

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The document provided is a Bidder Declaration form from the California Department of Fish and Wildlife. This form requires the prime bidder to provide information about any subcontractors that will be used for the contract, including their contact information, California certification status, and the percentage of work they will perform.

The related state and local contract opportunity is for an immersion vaccine to prevent Lactococcosis, a deadly fish disease caused by the bacterial pathogen Lactococcus petauri, in CDFW fish hatcheries. The contract will be awarded by the State of California. No additional details are provided about the quantities, response dates, award dates, or contract term.

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State of California – Department of Fish and Wildlife

BIDDER DECLARATION

DFW 1082 (REV. 09/30/21)

1. Prime bidder information:

a. What is your California vendor 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.

Authorizers printed name: _______________________________________ Date: _______________

Authorizers signature: ____________________________________________

Subcontractor Name, Contact Person, Phone Number & Email
Fix it Now
Authorizers Printed Name:
Date:
SAVE:
PRINT:
CLEAR:
What is your California vendor name:
MB SB DVBE:
None: Off
Will subcontractors be used for this contract Yes: Off
Will subcontractors be used for this contract No: Off
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:
Subcontractor Name Contact Person Phone Number and Email:
0:
Subcontractor Name Contact Person Phone Number and Email 1:
Subcontractor Name Contact Person Phone Number and Email 2:
Subcontractor Name, Contact Person, Phone Number and Email:
3:
Subcontractor complete address:
0:
1:
2:
3:
CA Certification Number MB SB DVBE or None 0:
CA Certification Number MB SB DVBE or None 1:
CA Certification Number (MB, SB, DVBE, or None) 2:
CA Certification Number MB SB DVBE or None 3:
Work performed or good provided for this contract 0:
Work performed or good provided for this contract:
1:
Work performed or good provided for this contract 2:
Work performed or good provided for this contract 3:
Corresponding percentage of bid price 0:
Corresponding percentage of bid price 2:
Corresponding percentage of bid price 1:
Corresponding percentage of bid price 3:

File details come from the government source that posted it. Updated .