DFW_1082.pdf

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Attached to
FB RFQ 24-089 Mojave River Fish Hatchery Autogenous Injection Vaccine
Solicitation number
0000033714
Issued by
San Bernardino County, California

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This is a Bidder Declaration form (DFW 1082) from the California Department of Fish and Wildlife, revised September 30, 2021. The form requires prime bidders to provide their California vendor name, current California certification numbers (MB/SB/DVBE), and declare whether subcontractors will be used for the contract.

The form includes a table for listing subcontractor details including name, contact information, complete address, California certification numbers, work to be performed, and corresponding percentage of bid price. An example is provided showing "Fix it Now" as a sample subcontractor performing office repairs at 25% of the bid price. The form requires certification under penalty of perjury with an authorizer's printed name, signature, and date. The document includes Save, Print, and Clear buttons at the top.

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State of California – Department of Fish and Wildlife

BIDDER DECLARATION

DFW 1082 (REV. 09/30/21)

1. Prime bidder information:

a. What is your California vendor name?

b. Identify your current California Certification(s) number(s):

(MB/SB/DVBE):_____________ or None (If “None”, proceed to number 2)

c. Will subcontractors be used for this contract? YES NO (If yes, indicate in the space below the distinct element of work your business will perform in this contract. If no, skip to the certification at the bottom of this page.)

2. If subcontractors will be used, list all subcontractors for this contract in the table below. (Attach additional pages if necessary):

EXAMPLE

Subcontractor Name, Contact Person, Phone Number & Email

Fix it Now John Smith Jr.

(916) 445-1234

JSmithJr@fixitnow.com

Subcontractor complete address

1234 Fix It Pl.

Sacramento, CA

95821

CA Certification Number (MB, SB, DVBE, or None)

SB # 15245

Work performed or good provided for this contract

Office repairs

Corresponding % of bid price 25%

CERTIFICATION: By signing this form (Bidder Declaration), I certify under penalty of perjury that the information provided is true and correct.

Authorizers printed name: _______________________________________ Date: _______________

Authorizers signature: ____________________________________________

Subcontractor Name, Contact Person, Phone Number & Email
Fix it Now
Authorizers Printed Name:
Date:
SAVE:
PRINT:
CLEAR:
What is your California vendor name:
MB SB DVBE:
None: Off
Will subcontractors be used for this contract Yes: Off
Will subcontractors be used for this contract No: Off
If yes indicate in the space below the distinct element of work your business will perform in this contract If no skip to the certification at the bottom of this page:
Subcontractor Name Contact Person Phone Number and Email:
0:
Subcontractor Name Contact Person Phone Number and Email 1:
Subcontractor Name Contact Person Phone Number and Email 2:
Subcontractor Name, Contact Person, Phone Number and Email:
3:
Subcontractor complete address:
0:
1:
2:
3:
CA Certification Number MB SB DVBE or None 0:
CA Certification Number MB SB DVBE or None 1:
CA Certification Number (MB, SB, DVBE, or None) 2:
CA Certification Number MB SB DVBE or None 3:
Work performed or good provided for this contract 0:
Work performed or good provided for this contract:
1:
Work performed or good provided for this contract 2:
Work performed or good provided for this contract 3:
Corresponding percentage of bid price 0:
Corresponding percentage of bid price 2:
Corresponding percentage of bid price 1:
Corresponding percentage of bid price 3:

File details come from the government source that posted it. Updated .