Contractor Information Form (rev. 5.24).pdf

PDF 1 MB Posted

Attached to
MVDC Plumbing Services
Solicitation number
SRC0000029498
Issued by
Lake County, Ohio

About this file

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The document is a Contractor Information Form, likely used for a state-level request for proposal (RFP) in Ohio. The form requires potential contractors to provide comprehensive company and employee details, including basic contact information, DODD (Department of Developmental Disabilities) certification status, OAKS Supplier ID or Tax Identification Number, and current employee demographics both nationwide and specific to Ohio operations.

The form is designed to collect critical vendor information for potential state contract opportunities, with a focus on verifying minimum qualifications outlined in the RFP. Key elements include reporting the current number of employees, percentages of women and minorities in the workforce, alternative remittance addresses, and contact information for the individual authorized to execute a contract. The form is marked as revision 5/2024 and explicitly states that it must be completed, signed, and submitted with the RFP proposal to be considered eligible for review and scoring.

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File Type Posted
MVDC Plumbing RFQ Document (Rnd 2).docx DOCX document
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 .