BIDDER RESPONSE FORM - Roadway Patch Materials.pdf

BIDDER RESPONSE FORM

DCR-903: ROADWAY PATCH MATERIALS

INITIAL DEADLINE FOR SUBMITTING RESPONSES IS FRIDAY, JULY 14, 2023 AT 4:00 PM EST

INSTRUCTIONS: Please complete this form electronically by typing directly into the boxes or clicking on checkboxes. Submission of a completed Bidder Response Form is MANDATORY. Be sure to read the instructions for each section carefully and thoroughly. Responses found to be incomplete may be disqualified or excluded from evaluation.

Bidder/Company Name:

Mailing Address:

(Street Address)

(City/Town) (State) (Zip Code)

Point of Contact Name:

Phone Number:

Email Address:

Please specify the number of years your company has been in business:

Ability to Provide Contract Commodities: Please specify which of the contract commodities listed below your company can provide:

• Hot Mix Asphalt (aka Bituminous Asphalt Concrete)

• Cold Patch

• Emulsion (supplied in 5-gallon pails)

Level of Service: please indicate below which days of the week your company operates and is able to supply the desired contract commodities:

< Please only check this box if you company is able to provide 7-day per week service.

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Geographic Service Areas: Please indicate which Massachusetts counties your company is able to provide delivery service to:

Please check this box only if your company is able to provide service throughout the entire Commonwealth of Massachusetts.

If your company is not able to service the entire Commonwealth of Massachusetts, please indicate which counties you are able to provide service. A map of Massachusetts counties is provided on the last page of this Bidder Response Form.

Berkshire County Middlesex County Plymouth County Franklin County Essex County Barnstable County Hampshire County Suffolk County Dukes County Hampden County Norfolk County Nantucket County Worcester County Bristol County

Vendor Plant Locations: Please use the spaces below to provide your company’s service locations where the contract commodities can be purchased/picked up:

LOCATION 1: LOCATION 4:

Street Address: Street Address:

City & State: City & State:

LOCATION 2: LOCATION 5:

LOCATION 3: LOCATION 6:

Pricing: Please use the space below to provide your company’s pricing for each of the contract commodities you are able to supply:

COMMODITY 1 – HOT MIX ASPHALT (BITUMINOUS ASPHALT CONCRETE)

Enter Price for 1 Ton of Asphalt (picked up by DCR at bidder’s plant): $

COMMODITY 2 – COLD PATCH

Enter Price for 1 Ton of Asphalt (picked up by DCR at bidder’s plant): $

COMMODITY 3 – EMULSION

Enter Price for 5 Gallon Bucket of Emulsion (picked up by DCR at bidder’s plant): $

Affirmation: By entering my name and information below, I hereby affirm that I have read, agree to, and will abide by (if awarded a contract) all of the terms and conditions outlined in the Request for Response (RFR) associated with this procurement and that the information provided in this Bidder Response Form is accurate and truthful.

Name Date

Title

Company Name

Street Address City/Town State Zip Code

Phone Number Email