Contractor Information Form (rev. 5.24).pdf

PDF 1 MB Posted

Attached to
Mount Vernon Developmental Center - Cabinets for Lincoln
Solicitation number
SRC0000033908
Issued by
Lake County, Ohio

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Written by GovTribe AI ·

This document is a Contractor Information Form used for a state-level Request for Proposal (RFP). The form requires potential contractors to provide comprehensive details about their organization, including basic contact information, employee demographics, DODD certification status, and OAKS Supplier ID or Tax Identification Number. The form is designed to collect key information for evaluating a contractor's eligibility and qualifications for a specific RFP.

The form requests specific details such as the current number of employees both nationwide and within Ohio, with a breakdown of the percentage of women and minorities in the workforce. Contractors must indicate whether they are DODD certified and provide contact information for the person authorized to execute a contract. The document emphasizes that the form must be completed, signed, and submitted with the RFP Proposal to be considered eligible for review and scoring, with a revision date of 5/2024. The form includes spaces for a remittance address different from the primary mailing address and requires an authorized signature and date.

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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 .