Contractor Information Form (rev. 5.24).pdf

PDF 1 MB Posted

Attached to
SODC Patient Lift State and local contract opportunity
Solicitation number
SRC0000029938
Issued by
Clermont County, Ohio

About this file

Written by GovTribe AI ·

The document is a Contractor Information Form revised in May 2024, designed for use in a state and local government procurement process. The form requires potential contractors to provide comprehensive company details necessary for bid submission, including basic contact information, employee demographics, DODD certification status, and OAKS Supplier ID or Tax Identification Number. Contractors must affirm they meet minimum qualifications specified in the Request for Proposal (RFP) and provide employee information both nationwide and specific to Ohio operations.

The form mandates submission of detailed organizational data, including current employee count, percentage of women and minority employees, remittance address (if different from mailing address), and contact information for the individual authorized to execute a contract. Contractors must sign and date the form, which is a required component of the RFP proposal process. The document emphasizes that without complete, signed submission, the proposal will not be considered eligible for review and scoring, underlining the importance of thorough and accurate information disclosure in the government contracting process.

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Other files for this state and local contract opportunity

Other files attached to SODC Patient Lift, newest first.
File Type Posted
STANDARD AFFIRMATION AND DISCLOSURE FORM (EO 2019-12D & 2022-02D).pdf PDF
SODC-Patient Lift RFQ.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 .