Comer Addition RFP _ Cabling.pdf

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Comer Elementary School Addition/Renovation - Low Voltage Data Cabling State and local contract opportunity
Solicitation number
PE-55127-NONST-2026-000000015
Issued by
Georgia

About this file

This is a Request for Proposal (RFP) issued by Madison County School System in Danielsville, Georgia, for low-voltage data cabling services for the Comer Elementary School Addition/Renovation project. The project encompasses installation of 281 total drops, including 68 access point drops, 61 camera drops, 88 data drops, 26 intercom drops, 18 clock drops, 7 outdoor horn drops, 9 door access control drops, and 4 Centegix system drops. The project is divided into two phases: Phase 1 involves addition of a cafeteria and 6 new classrooms with potential start date of July 2026, and Phase 2 involves renovation of existing spaces including the office and old cafeteria, scheduled to begin May 2027 and complete by July 31, 2027. The deadline for submitting written questions is July 10, 2026, with addenda posted by July 14, 2026. Proposals are due July 20, 2026, at 1:00 PM EST, with public bid opening at that time. Bid evaluations will occur July 20-23, 2026, with vendor interviews possible July 21-23, 2026, and recommendation to superintendent by July 23, 2026. The contract term begins immediately upon superintendent recommendation and concludes once the general contractor signs off on completed work.

Evaluation of proposals will be based on six weighted factors: price (30 points), qualifications and scope of work (20 points), prior experience (15 points), management capability (10 points), comprehensive integration (15 points), and references (10 points). Madison County School System reserves the right to reject any proposals, accept proposals from multiple vendors, and award portions of the project as deemed in the school system's best interest. The RFP includes mandatory requirements for cabling installation specifications, including use of Cat6 Plenum cable, Siemon Z-Max jacks and faceplates, 24-port patch panels, color-coded patch cables for different systems, proper cable management using Velcro and J-hooks, and specific data closet racking configurations. Payment terms are Net 30 with monthly invoicing, and prices must remain firm for one year from award date. Vendors must submit the RFP acknowledgement form, contract agreement, vendor questionnaire, vendor reference sheet, and detailed pricing and scope of work documentation. All documents submitted become property of Madison County School System.

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Madison County School System PO Box 37

800 Madison Street Danielsville, Georgia 30633

June 16, 2026

REQUEST FOR PROPOSAL

Comer Elementary School Addition/Renovation - Low Voltage Data Cabling RFP

MADISON COUNTY SCHOOL SYSTEM seeks proposals from qualified vendors for low voltage data cabling as outlined herein. Responses to this RFP are due on July 20, 2026 at 1:00 PM EST and must be delivered/addressed to:

MADISON COUNTY SCHOOL SYSTEM

P.O. Box 37 Danielsville, Georgia 30633 Attn. Amy Denman – Comer Elementary School Addition/Renovation - Low Voltage Data Cabling RFP

OR, if hand delivered:

MADISON COUNTY SCHOOL SYSTEM

800 Madison Street Danielsville, Georgia 30633 Attn. Amy Denman – Comer Elementary School Addition/Renovation - Low Voltage Data Cabling RFP

It is the responsibility of the responding vendors to ensure responses to this RFP are complete and delivered no later than the due date/time as outlined herein. Madison County School System reserves the right to refuse consideration of any late or incomplete responses to this RFP.

Vendors should submit their bids along with the required forms. Madison County School System may select the lowest priced items from multiple vendors.

Your interest and participation in this project are appreciated.

Sincerely, AMY DENMAN

Technology Director

Comer Elementary School Addition/Renovation Low Voltage Data Cabling RFP 2026

TABLE OF CONTENTS

Invitation to Respond to RFP.………………………………………………………….……….………1 General Terms and Conditions………………………………………………………… Special Terms and Conditions.……………………………………………………………...…....…….4 Scope of Work...………….………………….……………………………………….…….…...………..9 Attachment A: RFP Acknowledgement………………………………………………………………..12 Attachment B: Contract Agreement……………………………………………………………… Attachment C: Vendor Questionnaire…………………………………………………………...…….14 Attachment D: Reference Sheet……………………………………………………………………….15 Exhibit A: Comer Elementary School Addition/Renovation Map – Separate Document

GENERAL TERMS AND CONDITIONS

1. SCOPE

SCOPE OF WORK

It is the intention of Madison County Schools to contract with a vendor(s) to provide a high quality, cost- effective structured cabling system for this project. Please refer to EXHIBIT A (separate document) for drop and MDF locations. Included in this project are 68 access point drops, 61 camera drops, and 88 data drops, 26 intercom drops, 18 clock drops, 7 outdoor horn drops, 9 door access control drops, 4 Centegix system drops for 281 total.

It is very important to note that there are two phases to this project. Phase 1 is the addition of a cafeteria and 6 new classrooms. Phase 1 has already started and low voltage work could begin as early as July of 2026. Phase 2 is the renovation of existing spaces at Comer Elementary School including the office and old cafeteria. Phase 2 will begin in May of 2027 and must be completed by the end of July, 2027.

2. SUBMISSION OF RESPONSES

It is the responsibility of the responding vendors to ensure responses to this RFP are complete and delivered NO LATER than the due date/time as outlined herein. Madison County School System reserves the right to refuse consideration of any late or incomplete responses to this RFP.

3. AWARD OF CONTRACT

Madison County School System reserves the right to reject any and all responses to this RFP and/or to waive irregularities/technicalities of any and all responses to this RFP. Madison County School System will award any or all portions of this project as it deems to be in the best interest of the school system. Evaluation of responses will be so done as to be in accordance with the policies of the Madison County School System HERE and/or the State of Georgia and/or the United States Federal Government as required.

4. EXECUTION OF RESPONSE

All responses to this RFP must be accompanied by a manual signature of an authorized officer of the responding vendor. Responses must be typed with no erasures of any kind. Responding vendors must agree to the terms and conditions of this RFP as well as meet the requirements as outlined herein. Any exceptions made to mandatory terms and conditions of this RFP or failure to meet the requirements outlined herein may be interpreted by Madison County School System as failure to submit a qualified response by the vendor.

5. FURTHER CLARIFICATION

Madison County School System reserves the right to request further clarification of a response to this RFP made by any vendor to aid in the evaluation of this project’s award. Any further clarification deemed necessary for evaluation by Madison County School System is to be at the vendor’s expense.

6. OMISSIONS

Any omissions of detail specifications outlined herein that would result in incomplete satisfaction of the requirements of the RFP and/or incomplete operation of the systems for installation are not to be construed as to relieve the vendor of any responsibility or obligation to the complete and satisfactory delivery, operation and support of any and all requirements of the RFP.

7. PROJECT PAYMENT

A payment schedule will be agreed upon once the vendor is awarded the contract.

Payment is to be made upon correct invoicing being submitted to Madison County School System by the vendor. Vendor invoices should be submitted with Net 30 terms. Vendors will not contact the school district for payment prior to the end of the Net 30 term.

SPECIAL TERMS AND CONDITIONS

1. INTRODUCTION

Vendors are expected to incorporate all Special Conditions outlined herein in the response to this RFP. Special Conditions that vary from General Conditions take precedence.

1.1 PROJECT DESCRIPTION

Vendors will be required to submit responses for complete packages of this RFP. Once award(s) has been made, the Technology Director or a designee will work directly with the vendor schedule implementation. Madison County School System will make every effort to coordinate the projects with vendor(s) to minimize costs to the school system.

1.2 BASIC GUIDELINES FOR THIS REQUEST FOR PROPOSAL

Proposals will be evaluated in accordance with the following evaluation criteria:

FACTOR WEIGHT

Price 30 Points Qualifications (Technical)/Scope of Work 20 Points Prior Experience 15 Points Management Capability (Project Management) 10 Points Comprehensive Integration 15 Points References 10 Points

TOTAL 100 Points

1.3 SCHEDULE OF EVENTS

EVENT DATES

RFP released June 18, 2026 Deadline for submitting written questions July 10, 2026 Deadline for addendum posting by MCSS July 14, 2026 Proposals due to Madison County School System July 20, 2026 – 1:00 PM EST

*There will be a public opening of the bid documents and vendor names and proposal total will be listed. Bid evaluations will will not occur at the public opening.

OPTIONAL Proposal Opening July 20, 1:00 PM EST – Board of Education – PLC1 Bid Evaluations July 20-23, 2026.

Vendor interviews (if necessary) July 21-23, 2026 Recommendation to Superintendent July 23, 2026.

Deadline for beginning starting project – Vendor will immediately begin communications with the general contractor who will determine the schedule of work.

1.4 QUESTIONS

All questions concerning this RFP must be submitted in writing, email (preferred) to Amy Denman at the Madison County School System. No questions other than written will be accepted. Only written responses will be binding upon the school system.

Amy Denman P.O. Box 37, Danielsville, GA 30633 706-795-2191 x1427 Email: adenman@madison.k12.ga.us

Contract award(s) shall be made to the successful vendor(s) whose response(s) is deemed to be the best value to the school system, taking into account all of the evaluation factors set forth in this RFP. Madison County School System reserves the right to accept or reject any or all proposals submitted in response to this RFP.

2. DESCRIPTION OF REQUIREMENTS

2.1 INTRODUCTION

The Madison County School Technology Department has established certain requirements with respect to responses submitted by vendors. Whenever the terms should, shall, must, will or is required are used in the RFP, the specification being referred to is a mandatory requirement.

Failure to meet any mandatory requirement may cause rejection of the vendor’s proposal.

Whenever the terms can or may are used in the RFP, the specification is being referred to as desirable. Failure to provide any items so termed may not be cause for rejections, however, will probably cause a reduction in score awarded.

2.2 PROJECT OVERSIGHT AND STAFFING

The successful vendor(s) will report to the Technology Director or to a designee assigned by the Technology Director for all communication regarding the contract after the award is made.

2.3 PROJECT STARTUP

As soon as the award is made, the winning vendor will be contacted to arrange for implementation.

2.4 ATTACHMENT A: RFP ACKNOWLEDGEMENT FORM

Vendors must complete and return the RFP Acknowledgement Form, clearly answering all questions in their entirety. Note that this form also includes non-discrimination and non-collusion affidavits.

2.5 ATTACHMENT B: Contract Agreement

Vendors must complete and return the Contract Agreement, clearing answering all questions in their entirety.

2.6 ATTACHMENT C: Vendor Questionnaire

Vendors must complete and return the Vendor Questionnaire, clearing answering all questions in their entirety.

2.7 ATTACHMENT D: Vendor Reference Sheet

Vendors must complete and return the Vendor Reference Form, clearing answering all questions in their entirety.

mailto:adenman@madison.k12.ga.us

2.8 ATTACHMENT E: PRICING AND PROPOSAL

Vendors must provide pricing and proposal sheets as directed. This attachment will be created by each vendor.

3. PROPOSAL SUBMISSION

3.1 PRESENTATION OF RESPONSE

Emphasis on each response should be on completeness and clarity of content. Responses are expected to stand on their own with every effort being made to eliminate misinterpretation due to lack of clarity or information. Vendors are cautioned not to rely on post-bid clarification to explain any portion of its response as it is possible not all vendors will be invited to participate in post-bid further clarification should such a step be deemed necessary by Madison County School System.

To expedite the evaluation process, it is essential vendors follow any format and instructions contained herein.

3.2 PROPERTY RIGHTS

All documents, including but not limited to, data, drawings and specifications, submitted with response by the vendor become the property of the Madison County School System.

3.3 REQUIRED ORGANIZATION OF RESPONSE

Vendors must return all affidavits, attachments and any additional information as outlined herein.

Where additional information is requested/allowed, vendors should formulate the response on 8- 1/2” x 11” pages, typed in a font no smaller than 12 points. All pages must be clearly labeled.

Responses must be organized as follows:

Attachment A – RFP Acknowledgement Form Attachment B – Contract Agreement Attachment C - Vendor Questionnaire Attachment D – Vendor Reference Sheet Attachment E – Pricing and Scope of Work Details (Attachments as needed)

3.4 Madison County School System REVIEW OF RESPONSES

All responses received will be reviewed by the Madison County School System Technology Department to ensure all administrative requirements of the RFP package have been met by the vendor. Each response will be reviewed to ensure that the vendor submitted the package as outlined above and that all documents requiring signature have been signed. Failure to meet these requirements may be cause for rejection of proposal. Responses will be opened on July 20.

Review and scoring of the responses will take place September 12-13, 2026.

4. TERMS AND CONDITIONS

4.1 RFP AMENDMENTS

Madison County School System reserves the right to amend the RFP prior to the date of the proposal submission. All questions must be received no later than 12:00 PM EST on July 10, 2026. All addenda will be posted on the school system web site at https://www.madison.k12.ga.us/page/bidsproposal and will be distributed to all known responding vendors via email.

4.2 RESPONSE WITHDRAWAL

Prior to the response due date, a submitted response may be withdrawn by the vendor by submitting a written request to Amy Denman at MCSS. An authorized officer of the vendor must sign for the vendor in instances of withdrawal of response.

https://www.madison.k12.ga.us/page/bidsproposal

4.3 COST OF PREPARING PROPOSALS

The cost for developing the response is the sole responsibility of the vendor. Madison County School System will not provide reimbursement for such costs.

4.4 CONTRACT TERM

The contract term for this project begins immediately upon the recommendation to the superintendent. The contract term will end once the general contractor has signed off on the work completed.

All documents submitted in response to the RFP, including any attachments and appendices, will be incorporated into the contract. If any language of the response conflicts with the language of the RFP, the language of the RFP shall govern.

4.5 AMENDMENTS IN WRITING

No amendment to this Contract shall be effective unless it is in writing and signed by duly authorized representatives of the parties. No representation, request, instruction, directive or order, made or given by any official, employee or agent of Madison County School System, whether verbal or written, shall be effective to amend this agreement or excuse or modify performance hereunder unless reduced to a formal amendment and executed as set forth above. Vendor shall not be entitled to rely on any such representation, request, instruction, directive or order and shall not, under any circumstances whatsoever, be entitled to additional compensation, delay in performance or other benefit claimed for relying upon or responding to any such representation, request instruction, directive or order.

4.6 AUTHORITY

Each party warrants that such party has full power and authority to enter into and perform this contract. The person signing on behalf of each party represents that such person is duly authorized to enter into this contract on behalf of such party.

5. CHANGE OF PROJECT CONDITIONS

5.1 NOTICE OF DELAYS

Whenever the vendor(s) receives notice or obtains knowledge of any event or condition which will delay, or is likely to delay, the completion of the performance under this contract beyond the specified completion date, the vendor(s) shall notify Madison County School System Technology Department in writing within fifteen (15) calendar days after receiving such notice or obtaining such knowledge of the nature of the delay and its estimated duration; otherwise, the vendor(s) shall not be entitled to any extensions of the completion date.

5.2 CHANGE ORDERS

Madison County School System, without invalidating the contract, may order changes within the general scope of the products and services required by this contract by altering, adding to and/or deducting from the products and services to be performed. All such changes in services shall be in writing and shall be performed subject to the provisions in this contract.

5.3 CHANGE ORDER APPROVAL

The Technology Director must approve ALL change orders.

5.4 CONTRACT TERMINATION

Madison County School System reserves the right to cancel the contract if the vendor(s) fails to meet the terms and conditions therein. Madison County School System shall give the vendor(s) a written notice stating the vendor’s failure to meet contractual obligations. The vendor(s) shall have thirty (30) days from the date on the notification to correct contract violations. Failure to do so will result in cancellation of the contract thirty (30) days after the date of the cancellation letter.

5.5 ADDITIONAL CONTRACT REQUIREMENTS

The agreement shall terminate absolutely and without further obligation on the part of the School District at the close of the calendar year in which it was executed and the close of each succeeding calendar year for which it may be renewed.

The agreement will be interpreted in accordance with the laws of the State of Georgia, regardless of any conflict of law or rules that would require an application of law of another jurisdiction. Both the School District and the vendor expressly and irrevocably agree to:

(a) To be subject to personal jurisdiction in the State of Georgia regarding any controversy that may arise relating to the agreement; and

(b) Venue and jurisdiction shall be proper in the federal and state courts located or serving Madison County, Georgia, area.

[Vendor] and its agents, employees, and representatives shall indemnify and hold harmless the School District from and against any and all liability, claims, cost, loss and expenses resulting from negligent acts or omissions of [vendor] or its agents, employees or representatives.

Either party may terminate this agreement with or without cause upon ninety (90) days written notice to the other party.

SCOPE OF WORK

It is the intention of Madison County Schools to contract with a vendor(s) to provide a high quality, cost- effective structured cabling system for this project. Please refer to EXHIBIT A (separate document) for drop and MDF locations. Included in this project are 68 access point drops, 61 camera drops, and 88 data drops, 26 intercom drops, 18 clock drops, 7 outdoor horn drops, 9 door access control drops, 4 Centegix system drops for 281 total. Data Cabling Guidelines

1. When running cable:

a. Data drops must be suspended using J hooks.

b. Velcro must be utilized in dressing and bundling cable trunks.

i. Zip ties are not accepted.

ii. Electrical tape is not accepted.

2. If a wall must be penetrated a sleeve must be used. The sleeve must have a bushing or is rolled on each end of the sleeve.

a. A ready sleeve with pre-rolled ends are also accepted, thus bushings are not needed.

b. All firewalls must be protected. Use fire putty to seal sleeves penetrating firewalls.

3. On the field end of the camera drops a 25’, not to exceed cable maximum run of 328’, service loop is required. This service loop is for the future if the camera must be moved.

a. Suspend the 25’ service loop with a J hook. Do not leave it laying on the ceiling grid.

4. On the field end of data/AP drops at least a 6’, to exceed cable maximum run of 328’, service loop is required.

a. Suspend the 6’ service loop with a J hook. Do not leave it laying on the ceiling grid.

5. On the data closet end dress each patch panel trunk with Velcro. Take the trunk past the patch panel then back up to the patch panel as your service loop.

6. Siemon Z-Max Jacks are preferred.

a. Black in color.

7. Siemon Single Gang Faceplates are preferred.

a. Stainless Steel.

8. Cat6 Plenum is required for all drops.

a. The color will be specified prior to start of the project and is dependent on the ceiling color if there are any exposed beams. Otherwise, the data cable color should be blue.

9. Patch Panels are preferred to be 24 Port.

a. If a non, pre-populated patch panel is used and there are additional empty slots, those slots must be populated with jacks for future use.

b. Siemon 24 port patch panels are preferred.

c. Patch panels are required to be labeled by a label maker in alphabetical order.

10. 1’ “bootless” Cat6 patch cables are required.

a. Blue patch cables for data drops.

b. Yellow patch cables for camera drops.

c. Gray patch cables for access control drops.

d. White patch cables for AP drops.

e. Green patch cables for intercom drops.

f. Orange patch cables for Centegix drops.

11. Single Mode Fiber is required for all fiber trunks.

a. Armored Fiber is preferred.

b. Fusion Spliced pig tails or quick connectors are required.

c. All fiber must be installed in a fiber enclosure.

i. All fiber endpoints must be labeled with a label maker.

12. All data drops must be labeled on each end of the cable.

a. MDF is A and all other IDFs are B,C,D…Etc.

b. Patch panels are labeled in alphabetical order.

c. Label all drops the following way.

i. XYZ

1. X= Data Closet. Y= Patch Panel and Z= Drop number.

2. For example: AB01, AC04 and or AD04-06

ii. Cable ends may be labeled with a Sharpie or a label.

iii. Face plates are required to be labeled with a label maker.

13. When racking data closets please follow the following order.

a. Skip 1U

b. Fiber Drawer

c. Skip 1U

d. Metro E/Modem (If applicable.)

e. Skip 1U

f. Voice Gateway (If applicable.)

g. Skip 1U

h. 24 Port Patch Panel

i. 48 Port Switch

j. 24 Port Patch Panel

k. Skip 1U

l. 24 Port Patch Panel

m. 48 Port Switch

n. 24 Port Patch Panel

i. Follow the Patch Panel-Switch-Patch Panel throughout the entire data closet.

ATTACHMENT A: RFP ACKNOWLEDGEMENT

Required from all vendors

MADISON COUNTY SCHOOL SYSTEM

P.O. Box 37 Danielsville, Georgia 30633

Attn. Amy Denman – Comer Elementary School Addition/Renovation - Low Voltage Data

Cabling

OR, if hand delivered:

800 Madison Street Danielsville, Georgia 30633

Attn. Amy Denman – Comer Elementary School Addition/Renovation - Low Voltage Data

PROPOSAL DUE DATE: July 20, 2026 1:00 PM EST

PROPOSAL TITLE: Comer Elementary School Addition/Renovation - Low Voltage Data

PROPOSALS MUST BE RECEIVED NO LATER THAN DUE DATE.

TO BE COMPLETED BY VENDOR (Please Print or Type):

Vendor Name:

Vendor Mailing Address:

City, State, Zip Code:

F.E.I.D. Number:

S.P.I.N. Number:

Email Address:

Telephone Number:

Fax Number:

NON-DISCRIMINATION: The vendor certifies it does not discriminate against any employee or applicant for employment because of race, religion, color, sex or national origin.

Authorized Signature Representative Name (Please Print)

ANTI-COLLUSION: The signed vendor certifies that he or she has not divulged, discussed or compared his/her proposal with other vendor and has not colluded with any other vendor or parties to an offer whatsoever.

Note: No premiums, rebates or gratuities are permitted either with, prior to, or after any delivery of material. Any such violation will result in the cancellation and/or return of materials (as applicable) and the removal from the bid lists(s).

Authorized Signature Representative Name (Please Print)

ATTACHMENT B: Madison County School System CONTRACT AGREEMENT

Required from all vendors

THE CONTRACT AGREEMENT MUST BE COMPLETED BY THE OFFEROR AND RETURNED

WITH THE PROPOSAL PACKAGE.

We have carefully examined and fully understand the General and Special Terms and Conditions and related documents in providing Comer Elementary School Addition/Renovation - Low

Voltage Data Cabling to the Madison County School System and do agree to all terms and conditions by signing this document.

Withdrawals, cancellations, etc., will not be accepted unless the Purchasing Director gives authorization. In the event vendors fail to comply, they may be removed from the vendors’ list.

Company Name Representative’s Signature

(Must be signed in ink)

Address Representative’s Name

(Please type or print)

City, State, and Zip Code E-Mail Address

Date Telephone Number and Extension

Terms Net 30 days - monthly invoicing

PRICES MUST REMAIN FIRM FOR ONE YEAR FROM DATE OF AWARD.

Signing the Contract Agreement affirms that the original RFP document has not been altered in any way.

Upon notice of award, this page will become the prevailing Contract Agreement between your organization and the MCSS.

ATTACHMENT C: Madison County School System

VENDOR QUESTIONNAIRE

Questionnaire information will be utilized in the evaluation of this bid. Vendors must include all information requested. Failure to do so will reflect negatively in evaluation and may result in your submission being deemed “non-responsive” and eliminated from consideration.

Company Name:_______________________________________________________________ Years in Business______________________________________________________________ Number of Permanent Employees:________________________________________________ # Of Employees Assigned to MCSS for this Contract: ________________________________ How many Comparable Contracts do you currently have in Georgia? _____________________ How many of these Contracts are?

Government_____________________________ K-12 Education___________________________ Please list any school systems that your company currently has managed services contracts with.__________________________________________________________________________ Please provide the name and contact information for the Project Manager assigned to this contract?

Has your company ever failed to comply with any Government contract awarded? (Explain if yes)________________________________________________________________________ Has your company ever lost a contract to any local, state, or national government entity based on poor performance or breach of contract (Explain if yes)__________________________________________________________________________ Is your company currently suspended or debarred from any government entity? (Explain if yes)__________________________________________________________________________ Are there any judgments, claims, legal proceeding or lawsuits pending or outstanding against your company of any of its officers (Explain if yes)___________________________________ Is your company currently in bankruptcy proceedings or has it filed for bankruptcy in the past five years? (If Yes, please explain) ________________________________________________ Please provide with your submission your most recent financial statement and audit results.

Please initial if they are included____________ Or specify why they are not included_______________________________________________________________________

___________ 15

Please list any additional certifications, awards or recognitions that you feel would benefit MCSS in the award and execution of this contract – or any other relevant information:

ATTACHMENT D: Madison County School System

VENDOR REFERENCE SHEET

References will be utilized in the evaluation of this Proposal. Vendors must include all information requested. Failure to do so will reflect negatively in evaluation and may result in your submission being deemed “non-responsive” and eliminated from consideration. It is not the responsibility of MCSS to pursue and obtain incomplete and/or inaccurate reference information, to ensure that references respond to our reference request, or to consider references not listed on this form.

Reference 1:

School System Name or Company Name

Address, City, State, Zip Code

Name of Contact Person Telephone Number

E-Mail Address

Reference 2:

School System Name or Company Name

Address, City, State, Zip Code

Name of Contact Person Telephone Number

E-Mail Address

Reference 3:

School System Name or Company Name

Address, City, State, Zip Code

Name of Contact Person Telephone Number

E-Mail Address

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