Contractor_Information_Form__rev._5.24_.pdf

PDF 1 MB Posted

Attached to
MVDC Maintenance Building Roof Repair
Solicitation number
SRC0000036747
Issued by
Ohio

About this file

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This is a Contractor Information Form (Revision 5/2024) required for submission with a Request for Proposal (RFP) to the State of Ohio for the MVDC Maintenance Building Roof Repair project at Mount Vernon Developmental Center. The form serves as a mandatory eligibility document that must be completed, signed, and submitted with the RFP proposal for consideration and scoring. Contractors are required to affirm that they meet minimum qualifications identified in Part Two: Section IV of the RFP. The form collects essential contractor identification information including business name, street address, city, state, and ZIP code, along with offeror contact details such as name, phone number, and email address.

The form requires contractors to provide current employee information on both a nationwide basis and specifically for Ohio operations, including the total number of employees and demographic breakdowns showing the percent of women and minorities employed. Additional required information includes OAKS Supplier ID or Tax Identification Number, DODD certification status with applicable certification number if applicable, remit-to address if different from mailing address, and contact information for the person authorized to execute contracts on behalf of the contractor. The contractor must provide signatory information including name, title, and email address, and certify authorization through an authorized signature with date. All sections must be completed accurately as incomplete forms will be deemed ineligible for review.

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Other files

File Type Posted
STANDARD_AFFIRMATION_AND_DISCLOSURE_FORM__EO_2019-12D___2022-02D_.pdf PDF
Contractor_Certification_Statements.pdf PDF
Maintenance Building Roof Repair RFQ Document.docx DOCX document

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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 .