Contractor_Information_Form__rev._5.24_.pdf

PDF 1 MB Posted

Attached to
GDC Generator/Transfer Switch Preventive Maintenance
Solicitation number
SRC0000037939
Issued by
Gallia County, Ohio

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This is a Contractor Information Form required for submission with a Request for Proposal (RFP) from the State of Ohio for generator and transfer switch preventive maintenance services at the Gallipolis Developmental Center. The form must be completed, signed, and submitted with the RFP proposal to be considered eligible for review and scoring. The solicitation encompasses all testing, inspections, preventive maintenance, and repair services for identified generators and transfer switches at the facility.

The form requires contractors to provide comprehensive business information including company name, address, contact details, current employee counts broken down by nationwide and Ohio-specific operations, and the percentage of women and minority employees. Contractors must identify whether they hold DODD (Department of Developmental Disabilities) certification and provide either an OAKS Supplier ID or Tax Identification Number. Additional required information includes a remit-to address if different from the mailing address, contact information for the person authorized to execute the contract on behalf of the contractor, and certification of meeting minimum qualifications as outlined in Part Two, Section IV of the RFP. The form requires an authorized signature and date to validate submission.

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GDC__Generator_RFQ_Document_FY27.docx DOCX document
STANDARD_AFFIRMATION_AND_DISCLOSURE_FORM__EO_2019-12D___2022-02D_.pdf PDF
Contractor_Certification_Statements.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 .