Contractor_Information_Form__rev._5.24_.pdf

PDF 1 MB Posted

Attached to
TDC FLOORING 2025
Solicitation number
SRC0000026937
Issued by
Seneca County, Ohio

About this file

Written by GovTribe AI ·

This is a Contractor Information Form for the State of Ohio Department of Developmental Disabilities (DODD), revised as of May 2024. The form must be completed, signed, and submitted with RFP proposals to be considered eligible for review and scoring. The form requires contractors to affirm they meet minimum qualifications identified in Part Two: Section IV of an unspecified RFP.

The form collects essential contractor information including business name, address, contact details, DODD provider certification status, OAKS Supplier ID/Tax ID, and employee demographics both nationwide and for Ohio operations (including total employees, percentage of women, and percentage of minorities). It also requires information about remittance addresses if different from the mailing address, and contact details for the person authorized to execute contracts. The form appears to be part of a larger RFP package, though the specific RFP title and number are not pre-filled in the document.

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Other files

File Type Posted
Contractor_Information_Form__rev._5.24_.pdf PDF
RFQ_NEVADA_FLOORING.docx DOCX document
STANDARD_AFFIRMATION_AND_DISCLOSURE_FORM__EO_2019-12D___2022-02D_.pdf PDF
RFQ NEVADA FLOORING.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 .