Contractor Information Form (rev. 5.24).pdf

1 MB Posted

Attached to
TDC Fire Door repair/replace
Solicitation number
SRC0000024052
Issued by
Seneca County, Ohio

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The document provided is a Contractor Information Form for a state and local contract opportunity in Ohio. This solicitation is for the required repair and/or replacement of thirty-six (36) fire door assemblies to meet Medicaid inspection requirements at the Tiffin Developmental Center (TDC) in Seneca County, Ohio. The form must be completed, signed, and submitted with the proposal for the contractor to be considered eligible for review and scoring.

The form requests information about the contractor, including their DODD certification status, OAKS Supplier ID or Tax Identification Number, current employee information both nationwide and for Ohio operations, and contact information for the person with authority to execute a contract on behalf of the contractor.

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Other files

File Type Posted
TDC_Fire_Doors_RFQ_Document__002_ (2).docx DOCX document
STANDARD AFFIRMATION AND DISCLOSURE FORM (EO 2019-12D & 2022-02D).pdf PDF
TDC Fire Doors RFQ Document (002).docx DOCX document
STANDARD AFFIRMATION AND DISCLOSURE FORM (EO 2019-12D & 2022-02D).pdf PDF
Contractor Information Form (rev. 5.24).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 .