Contract_Intake_Form_01.24.docx

CONTRACT INTAKE FORM

All potential consultants/entities seeking a Contract, Agreement, Memorandum of Understanding, etc., with the Office of Superintendent of Public Instruction (OSPI), State Board of Education (SBE), Professional Educator Standards Board (PESB), or Financial Education Public-Private Partnership (FEPPP) must complete and return this form before a Contract or Agreement will be offered.

2. CONTRACTOR’S CONTACT INFORMATION:

OSPI will use the information below to send the final contract for signature through DocuSign. A DocuSign account is not necessary to accept or sign the contract/agreement.

STATE

ZIP CODE

CONTRACT MANAGER NAME

CONTRACT MANAGER’S EMAIL ADDRESS

CONTRACT MANAGER’S PHONE NUMBER

CONTRACTOR’S SIGNATORY (IF DIFFERENT THAN CONTRACT MANAGER): 2

NAME

EMAIL ADDRESS

ADDITIONAL INDIVIDUALS TO RECEIVE CONTRACT (IF DESIRED): 3

3. BUSINESS INFORMATION:

TAXPAYER IDENTIFICATION (TIN) NUMBER

For individuals, this is your Social Security Number (SSN). For other entities (corporations, school districts, etc.), this is your Employer Identification Number (EIN).

SSN: OR EIN:

STATEWIDE VENDOR (SWV) NUMBER

Contractors are required to register as a Statewide Vendor in order to receive payment from the State. Visit the Office of Financial Management for information or to register. To find your existing SWV#, visit OFM’s Statewide Vendor Number lookup.

SWV:

How is your business organized?

If a Corporation, non-profit, attach a copy of 501(c) status.

Do you have a current Washington State business license?

|_| Yes – Attach a copy or provide UBI#:

|_| No For assistance finding your organization’s legal name or UBI number, or if you would like more information about business license requirements, visit the Department of Revenue.

Have you had any contract to provide services terminated for default? |_| Yes |_| No If yes, attach a list of each terminated contract with an explanation of the situation.

Will a Subcontractor be used to fulfill any part of the work in the proposed contract/agreement? |_| Yes |_| No Subcontractor means one not in the employment of the Contractor, who is performing all or part of contracted services under a separate contract with the Contractor. The Contractor and all Subcontractors shall report and confirm receipt of payments made to the Contractor and each Subcontractor through the state’s Access Equity system. For information and/or help with the system visit the OMWBE Access Equity Help Center.

Is your business a small, woman-, minority-, or veteran-owned business as defined in Chapter 39.26.010 RCW?

4. WASHINGTON STATE EMPLOYMENT (ESDs, School Districts, and State Agencies check N/A):

Are you, or any of your business partners, directors, officers, managers, employees, or board members current or former (within the last 24 months) officers or employees of the State of Washington?

|_| Yes |_| No |_| N/A If yes: |_| Current or |_| Former District and ESD employees are not considered state employees for this purpose. As a reminder, check with your employer regarding their outside work policies.

If you checked Yes, you may be required to seek guidance from the Executive Ethics Board before a contract is offered; you may be contacted for clarification about your current/former role.

5. I certify, under penalty of perjury as provided by the laws of the State of Washington, that all of the foregoing statements are true and correct, and that I will notify the Agency of any changes.

CONTRACTOR SIGNATURE

DATE

PRINTED NAME

TITLE

Contract Manager is the Contractor’s person responsible for all communications and billings regarding the performance of the Contract/Agreement. Depending on your organization’s structure, this may or may not be the same person who will sign the Contract/Agreement. This is NOT the OSPI Contract Manager or contact person.

2 If the person signing the Contract/Agreement on behalf of the Contractor is different than the Contract Manager, both individuals will receive notices via DocuSign.

3 You may list additional individuals to sign the Contract/Agreement and/or receive a courtesy copy via DocuSign. If including additional signatories, list them in order they should be received.

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