Contractor_Information_Form__rev._5.24_.pdf

PDF 1 MB Posted

Attached to
SODC Commercial Dishwasher High Temperature State and local contract opportunity
Solicitation number
SRC0000029166
Issued by
Clermont County, Ohio

About this file

Written by GovTribe AI ·

The document is a Contractor Information Form designed for a state and local contract opportunity, likely in Ohio, to be used in conjunction with a Request for Proposal (RFP). The form requires potential contractors to provide comprehensive company details, including basic contact information, employee demographics, DODD (Department of Developmental Disabilities) certification status, and OAKS Supplier ID or tax identification number. The form must be completed, signed, and submitted with the RFP proposal to be considered eligible for review and scoring.

The form captures key organizational data such as the current number of employees both nationwide and specifically in Ohio, with breakdowns of the percentage of women and minorities in the workforce. Contractors must affirm they meet minimum qualifications specified in the RFP and provide contact information for the person authorized to execute a contract. Additionally, if the remittance address differs from the mailing address, contractors are required to provide those details. The form is marked with a revision date of 5/2024, indicating it is a current template for state contract submissions.

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File Type Posted
SODC-Commercial Dishwasher.pdf PDF
STANDARD_AFFIRMATION_AND_DISCLOSURE_FORM__EO_2019-12D___2022-02D_.pdf PDF

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CONTRACTOR INFORMATION FORM

STATE: ZIP CODE:

CONTRACTOR NAME:

STREET ADDRESS:

CITY:

OFFEROR CONTACT NAME:

PHONE NUMBER: EMAIL:

Current number of employees:

Percent of Women:

Percent of Minorities:

Authorized Signature Date

Contractor affirms that they meet the minimum qualifications identified in Part Two: Section IV of the RFP title:

This form must be completed, signed, and submitted with RFP Proposal for it to be considered eligible for review and scoring. Rev. 5/2024

1. DODD certified provider? NO YES, DODD Provider Certification #

2. Provide OAKS Supplier ID or Tax Identification Number:

3. Current employee information on both a nationwide basis (including Ohio), and for Ohio operations.

(enter RFP Title and RFP Number beginning with SRC)

Nationwide Ohio

4. If your remit to address is different than the mailing address above, pleas provide below:

Street Address:

City: State: Zip Code:

5. Provide contact information for person with authority to execute a contract on behalf of the contractor.

Name: Title:

Email:

Krista Shaw Line

Krista Shaw Line

Krista Shaw Line

STREET ADDRESS:
CITY:
STATE:
ZIP CODE:
PHONE NUMBER:
EMAIL:
NATIONWIDE 1:
NATIONWIDE 2:
NATIONWIDE 3:
OHIO 1:
Provide OAKS Supplier ID or Tax Identification Number:
Street Address:
Zip Code:
Date:
Check Box1: Off
CONTRACTOR NAME:
RFP Name & SRC #:
OHIO 2:
OHIO 3:
City:
State:
AUTHORIZED CONTACT NAME:
Signatory Name:
Signatory Title:
Signatory Email:
Check Box2: Off
Check Box3: Off
Certification #:

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