DLX Shelter Power Upgrade DQ RFAA 2026-0466 (2).pdf

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Attached to
DLX ASAP-18 Alternate Power System
Solicitation number
DQ1 RFAA 2026000466 1
Issued by
Denver County, Denver City, Colorado

About this file

DLX Shelter Power Upgrade Documented Quote Summary

This Documented Quote (DQ #RFAA 2026-0466) is issued by the Colorado Department of Public Safety, Purchasing and Contracts Unit for a DLX Shelter Power Upgrade project. The solicitation was published on May 5, 2026, with quotes due by Monday, May 11, 2026, at 2:00 PM Mountain Time. The estimated award selection and notification date is May 12, 2026, with an anticipated Purchase Order start date of May 15, 2026. The anticipated term of the resulting Purchase Order extends through June 30, 2026. All quotes must be submitted electronically via email to the Procurement Point of Contact, Nancy Guzman, at cdps_edo_bids@state.co.us with the subject line clearly identifying the respondent name and solicitation number. Respondents are required to submit a completed Signature Page and Exhibit B (Pricing) as part of their quote response.

Award will be made to the responsible respondent whose acceptable quote is determined most advantageous to the State, with price/cost being the primary consideration and other factors such as sample quality and lead time also evaluated. Proposed pricing must remain firm during the initial contract term and must include all fees associated with delivery and installation of goods or services. Service-Disabled Veteran-Owned Small Businesses (SDVOSBs) registered with the U.S. Small Business Administration and incorporated or maintaining a place of business in Colorado are eligible to receive a 3% preference on their quote price. Prior to Purchase Order execution, the awarded respondent must provide proof of Good Standing with the Colorado Secretary of State and an insurance certificate documenting required coverage. All quotes become property of the State, and respondents must certify independent price determination and disclose any potential conflicts of interest or anticipated performance outside Colorado or the United States.

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Documented Quote (DQ) #: RFAA 2026-0466:

Project Title: DLX Shelter Power Upgrade Date Due: Monday, May 11, 2026, at 2:00 PM MST

SIGNATURE PAGE

ISSUING OFFICE: Colorado Department of Public Safety, Purchasing and Contracts Unit The issuing office is the sole point of contract concerning this solicitation.

THIS IS A FILLABLE PDF FORM

FEIN Colorado VSS / CORE Number Date

Company Name

Address

City State Zip Code

Phone Email

Indicate if your company is registered and verified by the U.S. Department of Veteran Affairs as a Service-Disabled Veteran-Owned Small Business:

YES (if yes, please submit validation with your response) NO

Signature of Company Representative Signature by an authorized officer or agent of the company.

COMPLETE & RETURN WITH PROPOSAL SUBMISSION (ELECTRONICALLY)

All bid inquiries shall be emailed to cdps_edo_bids@state.co.us

Please ensure DQ # RFAA 2026-0046 is in the subject line of all communication.

Print Name of Company Representative Title mailto:cdps_edo_bids@state.co.us Nancy Guzman Cross-Out

Version 02.2026

Documented Quote (DQ)

DQ RFAA 2026-0466

DLX Shelter Power Upgrade

Due Date: Monday, May 11, 2026 @ 2PM MT

Version 02.2026

Documented Quote Summary Sheet

The information found in this summary sheet is for reference purposes only. Vendors or other interested parties are cautioned to review the solicitation, including any later amendments, in its entirety and contact the listed Point of Contact with any questions.

1. POINT OF CONTACT- NANCY GUZMAN

2. IMPORTANT DATES:

A. Publication Date- Tuesday, May 05, 2026

B. Quote Submission Deadline- Monday, May 11, 2026, at 2:00 PM MT

3. REQUIREMENTS:

A. Please see Exhibit A

4. REQUESTED QUOTE FORMAT:

A. Must submit Signature Page and Exhibit B – Pricing.

5. QUOTE SUBMISSION INSTRUCTIONS:

A. Respondents shall submit Quotes via email to the Procurement Point of Contact identified above. The Quote submission email should include the subject line

“Quote submission from (Insert Respondent Name) for DQ RFAA 2026-0466, DLX

Shelter Power Upgrade.

B. Ensure all requested attachments are included

C. A Quote received after the submission deadline may, at the sole discretion of the

State, be rejected without further consideration.

Version 02.2026 Documented Quote Page 1 of 12

TABLE OF CONTENTS

TABLE OF CONTENTS

1. SOLICITATION INFORMATION

A. Introduction

B. Anticipated Term

C. Schedule of Activities

D. Procurement Point of Contact

E. Respondent Inquiries

2. REQUIREMENTS

A. Accessibility Requirements

B. Insurance Requirements

C. Mandatory/Minimum Requirements

3. SCOPE OF WORK/SPECIFICATIONS

4. QUOTE SUBMISSION INFORMATION

A. Email Quote Submission Instructions

B. Timeliness of Quote Submission

C. Quote Format and Content

D. Pricing

5. AWARD

A. Basis for Award (See Procurement Rule R-24-103-204-01)

B. Negotiations

C. Single Quote

D. Notice of Award

E. Documents After Award

6. GENERAL ADMINISTRATIVE INFORMATION

A. Colorado Vendor Self Service

B. Modifications and/or Supplemental Information to the Solicitation

C. Solicitation Cancellation and/or Rejection of Quotes

D. Modifications or Withdrawal of Quotes

E. Mistake and Minor Informalities in Respondent Quotes

F. News Releases and Announcements

G. Not a Legally Binding Offer

H. Respondent Quote Content

Version 02.2026 Documented Quote Page 2 of 12

I. Quote Response Material Ownership

J. Certification of Independent Price Determination

K. Submission of Confidential or Proprietary Information

L. Ethics and Conflicts of Interest

M. Protested Solicitations and Awards

N. Performance Outside of Colorado

O. Service Disabled Veteran Owned Small Businesses (SDVOSB) (ref. §24-103-905, C.R.S., et seq

P. Vendor Assistance

Version 02.2026 Documented Quote Page 3 of 12

1. SOLICITATION INFORMATION

A. Introduction

On behalf of the State of Colorado, the Colorado Department of Public

Safety(CDPS) is issuing this Documented Quote for DLX Shelter Power Upgrade.

B. Anticipated Term

i. The anticipated term of the Purchase Order resulting from the award of this solicitation is through June 30, 2026.

ii. The State is not responsible for any goods delivered or services performed by the awarded Respondent without a State issued Purchase Order.

C. Schedule of Activities

i. This Schedule of Activities is for information and planning purposes only.

Schedules for Activities listed as “Estimated” may be subject to change depending on the needs of the State. All times are stated in Mountain Time

(MT), as adjusted for daylight savings.

a. The date of publication for this solicitation on Colorado VSS is Tuesday

May 05, 2026.

b. All quotes must be submitted in the method described below no later than Monday, May 11, 2026, at 2:00 PM MT

c. The estimated date for award selection and notification is May 12, 2026.

d. The estimated Purchase Order start date is May 15, 2026.

D. Procurement Point of Contact

i. The State’s sole point of contact for this solicitation is Nancy Guzman, who may be reached via email at cdps_edo_bids@state.co.us

E. Respondent Inquiries

i. Send all inquiries to the Procurement Point of Contact listed above. Inquiries should be clearly marked with the solicitation number and title. Where

Version 02.2026 Documented Quote Page 4 of 12 appropriate, inquiries should include references to any relevant Section and paragraph of the solicitation.

ii. Responses to Respondent inquiries will be published on Colorado VSS collectively, as an amendment to the solicitation. Respondents shall not rely on any verbal statements that alter any specification or other term or condition of the solicitation. Such changes are valid only if provided in writing by the Procurement Contact.

2. REQUIREMENTS

A. Accessibility Requirements

i. All work performed as a result of this solicitation must comply with all applicable provisions of §§24-85-101, C.R.S., et seq., and the Accessibility

Standards for Individuals with a Disability, as established by the Office Of

Information Technology pursuant to §24-85-103 (2.5), C.R.S. and 3) all State of Colorado technology standards related to technology accessibility and with

Level AA of the most current version of the Web Content Accessibility

Guidelines (WCAG), incorporated in the State of Colorado technology standards.

ii. See Exhibit D – Vendor Accessibility Requirements

B. Insurance Requirements

The awarded Respondent will be required to submit a certificate(s) of insurance evidencing insurance coverage for the types and amounts of insurance as required by the Insurance provision in the Purchase Order Terms and Conditions, included in this solicitation, prior to execution of the Purchase Order.

C. Mandatory/Minimum Requirements

i. See Exhibit A – Statement of Work

3. SCOPE OF WORK/SPECIFICATIONS

i. See Exhibit A - Statement of Work

4. QUOTE SUBMISSION INFORMATION

A. Email Quote Submission Instructions

Version 02.2026 Documented Quote Page 5 of 12

i. Respondents shall submit Quotes via email to the Procurement Point of

Contact identified above. The Quote submission email should include the subject line “Quote submission from (Insert Respondent Name) for DQ RFAA

2026-0466 DLX Shelter Power Upgrade.

ii. Quotes should be included as one or more attachments of commonly accessible file types.

B. Timeliness of Quote Submission

A Quote received after the submission deadline may, at the sole discretion of the

State, be rejected without further consideration.

C. Quote Format and Content

i. Complete Exhibit B - Pricing

D. Pricing

i. Proposed pricing must remain firm during the initial term of the Purchase

Order.

ii. Pricing must include any fees associated with the delivery of goods or services, including, but not limited to, shipping and installation.

iii. See Exhibit A – Statement of Work

5. AWARD

A. Basis for Award (See Procurement Rule R-24-103-204-01)

i. This solicitation and the resulting Purchase Order will be awarded to the responsible Respondent whose acceptable Quote is determined to be the most advantageous to the State, with price/cost being the primary consideration. Other considerations may include, but are not limited to, sample quality, and lead time for delivery.

ii. “Acceptable” means that the goods or services submitted in the Respondent’s

Quote will meet the state’s needs, and that the price is fair and reasonable.

The determination of whether a Respondent’s Quote is acceptable is solely within the State’s discretion.

Version 02.2026 Documented Quote Page 6 of 12

B. Negotiations

The State may negotiate with any Respondent to clarify the Respondent’s Quote or to effect modifications that will make the Quote Acceptable or more advantageous to the State; however, any requirements identified in this solicitation may not be negotiated. Reference Procurement Rule R-24-103-204-01(d).

C. Single Quote

If only one Quote is received in response to this solicitation, an award may be made to the single Respondent if the procurement official finds that the price submitted is fair and reasonable and that other prospective Respondents had reasonable opportunity to respond to the solicitation. If the price submitted is not fair and reasonable and there is not adequate time for re-solicitation, the procurement official may enter into competitive negotiations in accordance with

Procurement Rule R-24-103-208-02.

D. Notice of Award

A notice of the intent to award will be announced on Colorado VSS.

E. Documents After Award

Prior to Purchase Order execution, the awarded Respondent must provide the

State with proof of Good Standing with the Colorado Secretary of State and an insurance certificate documenting coverage as required by the Purchase Order.

6. GENERAL ADMINISTRATIVE INFORMATION

A. Colorado Vendor Self Service

i. This solicitation is being published on Colorado Vendor Self Service (Colorado

VSS), so that Offerors who have an interest may submit a proposal in accordance with the terms of this solicitation.

a. Vendors can self-register for this system free of charge, or may click on

“Public Access” on the website to view solicitation documents and modifications without registering. Vendors are encouraged but not required to register prior to or at the time they submit their response.

The State also recommends that interested vendors check Colorado VSS on a regular basis throughout this solicitation process.

http://www.colorado.gov/vss

Version 02.2026 Documented Quote Page 7 of 12

B. Modifications and/or Supplemental Information to the Solicitation

i. Any modifications, amendments or supplemental information to the solicitation will be published on Colorado VSS. A modification notice will be published on Colorado VSS in the event that it becomes necessary to revise any part of this solicitation.

ii. It is the Respondent’s sole responsibility to check Colorado VSS on a regular basis, prior to the Quote submission deadline, as this is the primary means for communicating any clarifications or changes to solicitation content, timeline and/or requirements.

C. Solicitation Cancellation and/or Rejection of Quotes

i. In accordance with §24-103-301, C.R.S., and the related Procurement Rules, the State may cancel this solicitation, or any and all Quotes may be rejected in whole or in part, without penalty, at any time before a Contract or purchase order is executed, when it is in the best interest of the State. The reason and documentation supporting the decision to cancel the solicitation or reject Quote(s) shall remain confidential for the lesser of six months or until a Contract or purchase order is awarded by the State. Reference

Procurement Rule R-24-101-401-05.

ii. If the solicitation is canceled after Quotes are received, the Quotes that have been opened shall be retained in the procurement record, or if unopened, they will be disposed of, or returned to the Respondent upon request at the

Respondents’ expense.

D. Modifications or Withdrawal of Quotes

A Respondent may modify or withdraw its Quote by written notice to the

Procurement Contact prior to the established Quote submission deadline.

Withdrawal of a Respondent’s Quote following the Quote submission deadline and prior to award, may be allowed, in the State’s discretion. Withdrawal of a

Respondent’s Quote after award is not allowed. Reference Procurement Rules R-

24-103-201-08 and R-24-103-201-09.

E. Mistake and Minor Informalities in Respondent Quotes

Version 02.2026 Documented Quote Page 8 of 12

In certain circumstances, a Respondent may correct a mistake(s) in its Quote and/or the State may waive minor informalities. Reference Procurement Rule R-

24-103-201-08.

F. News Releases and Announcements

Respondents shall not issue any news releases, communications or announcements of any kind pertaining to this solicitation, without prior written approval by the

State.

G. Not a Legally Binding Offer

Neither this solicitation nor a Respondent’s Quote submitted in response to this solicitation constitute a legally binding offer. Reference Procurement Rule R- 24-

103-204-01(b).

H. Respondent Quote Content

The contents of the Quote of the awarded Respondent and any modifications to the Quote negotiated by the State included in the resulting Purchase Order will become contractual obligations. Failure of the awarded Respondent to accept these obligations may result in cancellation of the award to that Respondent.

I. Quote Response Material Ownership

All material submitted in response to this solicitation becomes property of the

State.

J. Certification of Independent Price Determination

By submitting a Quote, the Respondent certifies that the prices and other terms in the Quote have been arrived at independently without any consultation, communication, agreement with, or knowledge of the contents of the Quote by any other competing Respondent. For purposes of this paragraph, "consultation, communication, agreement with, or knowledge" does not include knowledge of prices or terms gained through availability of established price lists or catalogues made available to the public by the competing Respondents. No attempt has been made or will be made by the Respondent to induce any other person or firm to submit or not to submit a Quote for restricting competition. Reference §6-4-101, C.R.S., et seq., (Colorado Antitrust Act of 1992) as amended.

Version 02.2026 Documented Quote Page 9 of 12

K. Submission of Confidential or Proprietary Information

i. The State of Colorado is subject to the requirements of §24-72-200.1, C.R.S., et seq., Colorado Open Records Act.

ii. A Respondent may submit, as a part of its Quote, a written request for classification of certain portions of the Quote as a trade secret or other confidential or proprietary information. Material for which the Respondent is requesting confidentiality shall be readily identifiable and separated from other portions of the Quote to facilitate public inspection of the non-confidential portion of the Quote. Commingling of confidential and non-confidential information is not acceptable. Neither price information nor any information that will be included in a resulting Purchase Order will be considered confidential.

iii. The Respondent must include the rationale for any request to classify portions as a trade secret or confidential or proprietary, including references to the authority that allows for such treatment.

iv. A complete redacted Quote response should also be included along with an unredacted Quote and confidentiality justification.

v. In no event shall an entire Quote be classified as confidential. The

Procurement Official or his or her designee shall determine if the information identified in the Respondent’s request is exempt from disclosure in accordance with §24-72-204, C.R.S., and shall inform the Respondent in writing of his or her determination. If the Respondent does not agree with the determination, the Respondent may protest the determination in accordance with article 109 of the Colorado Procurement Code and the terms of this solicitation. Reference Procurement Rule R-24-101-401-03.

vi. Any additional Respondent information, which may be part of the evaluation/negotiation process and for which a Respondent claims confidentiality, is subject to the same requirements and processes identified above.

Version 02.2026 Documented Quote Page 10 of 12

L. Ethics and Conflicts of Interest

i. The Respondent must disclose in its Quote any potential or actual conflict of interest in connection with a response to this solicitation. A conflict of interest may include, but is not limited to, access to any non-public information by the Respondent regarding the solicitation or its subject matter.

ii. The Respondent acknowledges that even the appearance of a conflict of interest may be harmful to the State’s interests. The Respondent shall disclose in its Quote whether there currently is, or potentially could be, the appearance of a conflict of interest regarding this solicitation, its staff, any proposed subcontractors or partners, or any related business with the State.

iii. Requirements set forth in this Section are continuing requirements throughout the solicitation process and, for the awarded Respondent, the

Contract or Purchase Order term, including any extensions. Reference §24-18-

201, C.R.S., et seq. (Proscribed Acts Related to Contracts and Claims); §24-

50-507, C.R.S.(Conflict of Interest); §18-8-301, C.R.S., et seq. (Bribery and

Corrupt Influence); §18-8-401, C.R.S., et seq. (Abuse of Public Office); §6-4-

101, C.R.S., et seq., (Colorado Antitrust Act of 1992); §24-109-105, C.R.S

.(Debarment and Suspension); and Procurement Rule R-24-101-107-01

(Ethics).

M. Protested Solicitations and Awards

An aggrieved party may file a protest concerning a Material Issue(s), at any phase of solicitation, including but not limited to, specifications, award or a disclosure of information marked confidential in the Quote. “Material issue” means a nontrivial defect in the solicitation or award that would prejudice the outcome of the procurement. The presence of multiple nonmaterial issues in a solicitation or award does not constitute a material issue unless the aggrieved party can establish that those nonmaterial issues together would prejudice the outcome of the procurement.” The protest shall be submitted to the Department of Public Safety

Procurement Official within three (3) business days after such aggrieved person

Version 02.2026 Documented Quote Page 11 of 12 knows, or should have known, of the facts giving rise thereto. Reference §24-109-

102, C.R.S., as amended, and Procurement Rule R-24-109-102-01, et seq. Protests should be submitted via email to tammy.lichvar@state.co.us.

N. Performance Outside of Colorado

Awarded Respondent, per Section 24-102-206, C.R.S., prior to contracting shall disclose in a written statement whether it anticipates performing or subcontracting any services under the contract, where such subcontracted services will be performed under the contract, including any subcontracts, and whether any subcontracted services under the contract or any subcontracts are anticipated to be performed outside the United States or the state. If the prospective vendor anticipates services under the contract or any subcontracts will be performed outside the United States or the state, the vendor shall provide in its written statement a provision setting forth why it is necessary or advantageous to go outside the United States or the state to perform the contract or any subcontracts.

O. Service Disabled Veteran Owned Small Businesses (SDVOSB) (ref. §24-103-905, C.R.S., et seq

i. SDVOSB Respondents must submit documentation of certification issued through the U.S. Small Business Administration in their Quote. §24-103-905

C.R.S. sets a SDVOSB goal of at least 3% of all contracts by dollar value be awarded to SDVOSBs who must be incorporated or organized in Colorado or they must maintain a place of business or have an office in Colorado and must be officially registered and verified as a SDVOSB by the United States Small

Business Administration.

ii. Verified SDVOSB Offerors shall receive a preference of 3% on their Quote.

This preference applies only to the Quote price, and the SDVOSB Respondent must still meet all other requirements of this solicitation.

P. Vendor Assistance

Any vendors needing support responding to solicitations may contact the Colorado

Supplier Diversity Navigator at the Statewide Equity Office of Supplier Diversity.

mailto:tammy.lichvar@state.co.us https://urldefense.proofpoint.com/v2/url?u=https-3A__dhr.colorado.gov_statewide-2Dequity-2Doffice_supplier-2Ddiversity&d=DwMFaQ&c=sdnEM9SRGFuMt5z5w3AhsPNahmNicq64TgF1JwNR0cs&r=2K9kkYDPzg9W7wrnb9URPPzWuzXzmzc6oQUqmP_d9mA&m=UsSCoCc_Nnj_It7iTj2w9Xh-U0kW8zKwh7sIdTrgvW_OXQDDQG8CMBmOZsCmKo6l&s=AHk9LQL8xQKwtYW6AlMhIpKhc64M4gHnBm1wvGiKqhU&e=

Version 02.2026 Documented Quote Page 12 of 12

Services provided include assistance with responding to solicitations, interpretation of solicitation documents, technical assistance referrals, availability of resources, construction bond assistance through the Construction Statewide

Bond Assistance Program, and free business directory listings and verifications through the Colorado Supplier Diversity Directory. The office can be reached during normal business hours by calling 303-866-5765 or emailing DPA_SupplierDiversityHelp@state.co.us.

https://urldefense.proofpoint.com/v2/url?u=https-3A__dhr.colorado.gov_supplier-2Ddiversity_construction-2Dand-2Dbond-2Dassistance&d=DwMFaQ&c=sdnEM9SRGFuMt5z5w3AhsPNahmNicq64TgF1JwNR0cs&r=2K9kkYDPzg9W7wrnb9URPPzWuzXzmzc6oQUqmP_d9mA&m=UsSCoCc_Nnj_It7iTj2w9Xh-U0kW8zKwh7sIdTrgvW_OXQDDQG8CMBmOZsCmKo6l&s=zAjgTZu5BkDViYCi42ZSaaEFbnZ4EzaMtQulSrBPsw8&e= https://urldefense.proofpoint.com/v2/url?u=https-3A__dhr.colorado.gov_supplier-2Ddiversity_construction-2Dand-2Dbond-2Dassistance&d=DwMFaQ&c=sdnEM9SRGFuMt5z5w3AhsPNahmNicq64TgF1JwNR0cs&r=2K9kkYDPzg9W7wrnb9URPPzWuzXzmzc6oQUqmP_d9mA&m=UsSCoCc_Nnj_It7iTj2w9Xh-U0kW8zKwh7sIdTrgvW_OXQDDQG8CMBmOZsCmKo6l&s=zAjgTZu5BkDViYCi42ZSaaEFbnZ4EzaMtQulSrBPsw8&e= https://urldefense.proofpoint.com/v2/url?u=https-3A__dhr.colorado.gov_supplier-2Ddiversity_colorado-2Dsupplier-2Ddiversity-2Ddirectory&d=DwMFaQ&c=sdnEM9SRGFuMt5z5w3AhsPNahmNicq64TgF1JwNR0cs&r=2K9kkYDPzg9W7wrnb9URPPzWuzXzmzc6oQUqmP_d9mA&m=lJCgtcQ4bpjUYTb-DL2vTiTtjs5tP9GdjxCxohJukG4cRYarpnnyVjmEkozBFRPl&s=nq-3ZxXvzK0CyjE_Sukw4DfkzHfxneqrfzbnzxsO-hw&e= mailto:DPA_SupplierDiversityHelp@state.co.us

DQ Signature Page
Signature Page
DLX Shelter Power Upgrade DQ RFAA 2026-0466.pdf
Documented Quote (DQ)
Due Date: Monday, May 11, 2026 @ 2PM MT
1. Point of Contact- nancy guzman
2. Important Dates:
3. Requirements:
A. Please see Exhibit A
4. Requested QUOTE Format:
5. QUOTE Submission Instructions:
TABLE OF CONTENTS
1. SOLICITATION INFORMATION
A. Introduction
B. Anticipated Term
C. Schedule of Activities
D. Procurement Point of Contact
E. Respondent Inquiries
2. REQUIREMENTS
A. Accessibility Requirements
B. Insurance Requirements
C. Mandatory/Minimum Requirements
3. SCOPE OF WORK/SPECIFICATIONS
4. QUOTE SUBMISSION INFORMATION
A. Email Quote Submission Instructions
B. Timeliness of Quote Submission
C. Quote Format and Content
D. Pricing
5. AWARD
A. Basis for Award (See Procurement Rule R-24-103-204-01)
B. Negotiations
C. Single Quote
D. Notice of Award
E. Documents After Award
6. GENERAL ADMINISTRATIVE INFORMATION
A. Colorado Vendor Self Service
B. Modifications and/or Supplemental Information to the Solicitation
C. Solicitation Cancellation and/or Rejection of Quotes
D. Modifications or Withdrawal of Quotes
E. Mistake and Minor Informalities in Respondent Quotes
F. News Releases and Announcements
G. Not a Legally Binding Offer
H. Respondent Quote Content
I. Quote Response Material Ownership
J. Certification of Independent Price Determination
K. Submission of Confidential or Proprietary Information
L. Ethics and Conflicts of Interest
M. Protested Solicitations and Awards
N. Performance Outside of Colorado
O. Service Disabled Veteran Owned Small Businesses (SDVOSB) (ref. §24-103-905, C.R.S., et seq
P. Vendor Assistance
Colorado VSS CORE Number:
Date:
Company Name:
Address:
City:
State:
Zip Code:
Phone:
Email:
Print Name of Company Representative:
Title:
Check Box1: Off
Check Box2: Off

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