Contractor Information Form (rev. 5.24).pdf
PDF 1 MB Posted
- Attached to
- Legal Hearing Examiners
- Solicitation number
- SRC0000029939
- Issued by
- Ohio
About this file
The Contractor Information Form is a standardized state document designed for potential contractors to provide comprehensive company details when responding to a Request for Proposal (RFP). The form requires contractors to submit key organizational information, including contact details, employee demographics, DODD certification status, and OAKS Supplier ID or Tax Identification Number. Contractors must affirm they meet minimum qualifications specified in the RFP and provide employee information for both nationwide and Ohio-specific operations.
The form captures critical vendor data including current employee count, workforce diversity percentages (women and minorities), and contact information for the individual authorized to execute a contract. Contractors must indicate whether they are a DODD certified provider and provide alternate remittance address if different from the primary mailing address. The document is mandatory for RFP submission, with a revision date of 5/2024, and requires an authorized signature to be considered eligible for review and scoring.
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Text version
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 #: |
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