BidIntentForm_2017-DOC-Vending Machines.doc
DOC document 64 KB Posted
- Attached to
- 2017-DOC-Vending Machines
- Solicitation number
- BD-17-1025-DOCFS-FISCM-15167
- Issued by
- Suffolk County, Massachusetts
About this file
The document provided is a Request for Response (RFR) for Vending Machine Operations issued by the Massachusetts Department of Correction (DOC) under RFR# 2017-DOC-Vending Machines with COMMBUYS Bid# BD-17-1025-DOCFS-FISCM-15167. The RFR seeks interested bidders to provide vending machine services at DOC facilities. Bidders must complete a Bid Intent Summary Form and a Background Information Request and Waiver form for each employee who will be attending the mandatory bidder's conference and/or site visit, which must be submitted by May 15, 2017, at 2:00 PM. The contract term and any renewal options are not specified in the document.
The document does not provide details on pricing terms, set asides, incumbents, funding requirements and sources, or other salient commercial information. Bidders are required to volunteer their Social Security Number and Driver's License information to aid in the background investigation process conducted by the DOC.
View the file
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Text version
REQUEST FOR RESPONSE
Vending Machine Operations
RFR# 2017-DOC-Vending Machines COMMBUYS Bid#: BD-17-1025-DOCFS-FISCM-15167
BID INTENT S U M M A R Y FORM
Must be received at DOC Central Headquarters , 50 Maple Street, Suite 3, Milford , MA 01757, Attention: Brian J. Kearnan by no later than
May 15, 2017 by 2:00 PM
Attention: Brian J. Kearnan, Contract Manager
Email or Fax to DOC Central Headquarters
Email: Brian.Kearnan@MassMail.State.MA.US
Fax number: 508-422-3383
Milford, MA 01757
RFR#: 2017-DOC-Vending Machines
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:
Driver’s
Is Background
| Employee Name (Print) |
| Date of Birth |
| License No. * |
| State |
| Info attached? |
Yes
Yes
Yes
Company Name (Print/Type)
| Individual Completing this Form (Print/Type) |
| Your 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.
BACKGROUND INFORMATION REQUEST and WAIVER
Must be received no later than by May 15, 2017 by 2:00PM
INSTITUTION / DIVISION
DATE:
(Leave blank)
CONTRACT EMPLOYEE
X
| PERSONAL DATA |
| (Please PRINT clearly or TYPE) |
NAME:
| Last |
| First |
| Initial |
Previous name and/or alias:
Residential Address:
| (Not a P.O.Box number) |
| Number |
| Street |
| City |
| St |
| 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 your current Drivers License No (Voluntary)*:
Your current Driver’s License is issued from which state?
| Date of birth: |
| / |
| / |
Place of birth:
Mother’s Maiden Name:
Father’s 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
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