FBO-RFQ-19-03-Podiatry.doc

REQUEST FOR QUOTATIONS

(THIS IS NOT AN ORDER)

1. REQUEST NO.

CRHC-19-03

2. DATE ISSUED

2/27/2019

3. REQUISITION/PURCHASE REQUEST NO.

IHS1368780

4. CERT.FOR NAT. DEF.

UNDER BDSA REG.2

AND/OR DMS REG. 1

RATING

5A. ISSUED BY

Eagle Butte Indian Health Service, Cheyenne River Service Unit 24276 166th St, PO Box 1012, Eagle Butte, SD 57625

6. DELIVER BY (Date)

See Below

FORMCHECKBOX

FOB DESTINATION FORMCHECKBOX

(See Schedule)

NAME

Stephanie Charger stephanie.redelk@ihs.gov

AREA CODE

NUMBER

964-0507

a. NAME OF CONSIGNEE

Cheyenne River Service Unit

24276 166th St , PO Box 1012

a. NAME

b. COMPANY

c. CITY

Eagle Butte

c. STREET ADDRESS

d. CITY

e. STATE

f. ZIP CODE

d. STATE

SD

e. ZIP CODE

57625

10. PLEASE FURNISH QUOTATIONS TO

THE ISSUING OFFICE IN BLOCK

5a ON OR BY 1:00 PM MST ON (Date) March 14, 2019 IMPORTANT: This is a request for information, and quotations furnished are not offiers. If you are unable to quote, please so indicate on this form and return it to the address in Block 5a. This request does not commit the Government to pay any costs incurred in the preparation of the submission of this quotation or to contract for supplies or services. Supplies are of domestic origin unless otherwise indicated by quoter. Any representations and/or certifications attached to this Request for Quotations must be completed by the quoter.

11. SCHEDULE (Include applicable Federal, State and local taxes)

ITEM NO.

(a)

SUPPLIES/SERVICES

(b)

QUANTITY

(c)

UNIT

(d)

UNIT PRICE

(e)

AMOUNT

(f)

Firm Fixed-Price, Non-Personal Healthcare Service Delivery Order for Podiatry Services at the Cheyenne River Health Center located in Eagle Butte, SD. The Period of Performance will be a Base + 4 Option Years. Contractor shall perform in accordance with the PWS. The quoted “unit price” shall be an all inclusive price.

12. DISCOUNT FOR PROMPT

PAYMENT

a. 10 CALENDAR DAYS

b. 20 CALENDAR DAYS

c. 30 CALENDAR DAYS

d. CALENDAR DAYS

NUMBER

PERCENTAGE

NOTE: Additional provisions and representations FORMCHECKBOX are FORMCHECKBOX are not attached.

SIGN QUOTATION

15. DATE OF

QUOTATION

a. NAME OF QUOTER

b. STREET ADDRESS

a. NAME (Type of print)

b. TELEPHONE

AREA CODE

AUTHORIZED FOR LOCAL REPRODUCTION

FormFlow/Delrina Inc.

STANDARD FORM 18 (REV 6-95) Previous edition not usable

Prescribed by GSA-FAR (48 CFR) 53-215-1(a)

ITEM NO.

(a)

SUPPLIES/SERVICES

(b)

QUANTITY

(c)

UNIT

(d)

UNIT PRICE

(e)

AMOUNT

(f)

1.

2.

3.

4.

5.

3 days a month x 12 months = 36 days a year x 8 hrs a day = 288 hrs a year

Base Year: 04/01/2019 – 03/31/2020 Option Year One(1): 04/01/2020 – 03/31/2021

Option Year Two(2): 04/01/2021 – 03/31/2022

Option Year Three(3): 04/01/2022 – 03/31/2023

Option Year Four(4): 04/01/2023 – 03/31/2024

DUNS & Bradstreet Number:

(The Duns & Bradstreet number is required. Provided you do not have it, you may call 866-705-5711 and obtain one.) You will need a DUNS & Bradstreet NUMBER to be awarded the purchase order and registered with the System for Award Management; you can register at www.sam.gov The quoter is hereby notified that they must be registered in the System for Award Management (SAM) before the Government will issue an award. You may do this by going to www.sam .gov to register and you are required to update this registration every year prior to the expiration date.

Federal Tax ID Number:

Email Address:

Net Terms:

Hr Hr

Hr

TOTAL: