DFW1082ext.pdf
PDF 1 MB Posted
- Attached to
- NR24-004 Seed Mix
- Solicitation number
- 0000032234
- Issued by
- Shasta County, California
About this file
The document is a Bidder Declaration form for the State of California Department of Fish and Wildlife (CDFW) contract opportunity. The contract requires the provision of a seed mix comprised of 12 seed varieties and rice hulls for distribution, to be delivered and off-loaded at the CDFW office in Yreka by October 1, 2024. The form collects information on the prime bidder, including their California vendor name, certification status (MB/SB/DVBE), and whether subcontractors will be used. If subcontractors are utilized, the form requires their name, contact information, certification status, the work they will perform, and the corresponding percentage of the bid price.
The contract opportunity is identified as NR24-004 Seed Mix and is located in Siskiyou County, California. The form requires the bidder's authorized representative to certify the information provided under penalty of perjury, and to acknowledge that their electronic signature is legally binding.
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| File | Type | Posted |
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| Answers_to_questions_for_event_32234.docx | DOCX document | |
| RFQ_NR24-004).docx | DOCX document |
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Text version
State of California – Department of Fish and Wildlife
BIDDER DECLARATION
DFW 1082 (REV. 05/15/23)
1. Primebidder information:
a. What is your California vendor’s 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.
With accordance to California Civil Code §1633.5(b), I acknowledge that by providing my electronic signature for this form, I agree that my electronic signature is legal binding equivalent to a handwriting signature. I hereby confirm that my electronic signature represents my execution or authentication of this form, and my intent to be bound by it.
Authorizer’s printed name: _______________________________________ Date: ______________
Authorizer’s signature: ____________________________________________ https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fleginfo.legislature.ca.gov%2Ffaces%2Fcodes_displaySection.xhtml%3FsectionNum%3D1633.5%26lawCode%3DCIV&data=05%7C01%7CLucia.Rodriguez%40wildlife.ca.gov%7Cf7d61fe8902f4fc2ddc908db44de0a8a%7C4b633c25efbf40069f1507442ba7aa0b%7C0%7C0%7C638179492686187568%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=SgmSIctaufa78R%2BCFlJqmUDsiiE%2FYw%2FCR%2BZhi4%2BcxQ0%3D&reserved=0
| Subcontractor Name, Contact Person, Phone Number & Email |
| Fix it Now |
| MBSBDVBE: |
| Authorizers printed name: |
| Date: |
| California Vendor Name: |
| Yes: Off |
| No: Off |
| If yes,: |
| Subcontractor Name4: |
| Subcontractor Name3: |
| Subcontractor Name2: |
| Subcontractor Name1: |
| Subcontractor Address1: |
| Subcontractor Address2: |
| Subcontractor Address3: |
| Subcontractor Address4: |
| CA Cert Number1: |
| CA Cert Number2: |
| CA Cert Number3: |
| CA Cert Number4: |
| Work Performed1: |
| Work performed2: |
| Work performed3: |
| Work performed4: |
| Corresponding percent1: |
| Corresponding percent2: |
| Corresponding percent3: |
| Corresponding percent4: |
| SAVE: |
| PRINT: |
| CLEAR: |
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