DOA-3832BidderRequiredFormRevised.doc

State of Wisconsin

Department of Administration

DOA-3832 (c01/2018) S. 16.72 Wis. Stats

State Bureau of Procurement

101 East Wilson Street, 6th Floor

P. O. Box 7867

Madison, WI 53707-7867

Bidder Required Form Instructions: Bidder is required to complete all sections of this form. (Note: If the agency checks the box preceding Section 5 indicating that section is not applicabe to the bid/proposal, Bidder may skip Section 5. Bidder may not skip any other sections of this form).

To be completed by the agency:

Agency Name UW Milwaukee

Solicitation Title

AUDIOLOGY EQUIPMENT, ACCESSORIES AND SUPPLIES

Solicitation Reference Number

KK21-01-O

Section 1: Bidder Information

Phone Number:

Toll Free Phone:

Fax:

Address:

Mailing Address for Purchase Orders (if different than above)

Address:

City:

Section 2: Bidder Contacts

List the name and title of the person to contact for questions related to each of the topics below:

Topic

Bid/Proposal

Affirmative Action Plan

Orders and billing

Section 3: Bidder Reference Provide company name, address, contact person, telephone number, and appropriate information on the product(s) and/or service(s) used with requirements similar to those included in this solicitation document. If vendor is proposing any arrangement involving a third party, the named references should also be involved in a similar arrangement.

Company Name:

Address (including City, State, Zip):

Contact Person:

E-Mail Address:

Phone:

List Product(s) and/or Service(s) Used:

Company Name:

Address (including City, State, Zip):

Contact Person:

E-Mail Address:

Phone:

List Product(s) and/or Service(s) Used:

Company Name:

Address (including City, State, Zip):

Contact Person:

E-Mail Address:

Phone:

List Product(s) and/or Service(s) Used:

Company Name:

Address (including City, State, Zip):

Contact Person:

E-Mail Address:

Phone:

List Product(s) and/or Service(s) Used:

Section 4: Designation of Confidential and Proprietary Information The attached material submitted in response to this bid/proposal includes proprietary and confidential information which qualifies as a trade secret, as provided in s. 19.36(5), Wis. Stats., or is otherwise material that can be kept confidential under the Wisconsin Open Records Law. As such, we ask that certain pages, as indicated below, of this bid/proposal response be treated as confidential material and not be released without our written approval.

Prices always become public information when bids/proposals are opened, and therefore cannot be kept confidential.

Other information cannot be kept confidential unless it is a trade secret. Trade secret is defined in s. 134.90(1)(c), Wis. Stats., as follows: “Trade Secret” means information, including a formula, pattern, compilation, program, device, method, technique or process to which all of the following apply:

1. The information derives independent economic value, actual or potential, from not being generally known to, and not being readily ascertainable by proper means by, other persons who can obtain economic value from its disclosure or use.

2. The information is the subject of efforts to maintain its secrecy that are reasonable under the circumstances.

We request that the following pages not be released:

Using the boxes below, indicate your agreement with the following statements:

FORMCHECKBOX

FORMCHECKBOX

In the event the designation of confidentiality of this information is challenged, the bidder/proposer hereby agrees to provide legal counsel or other necessary assistance to defend the designation of confidentiality and agrees to hold the state harmless for any costs or damages arising out of the state’s agreeing to withhold the materials.

FORMCHECKBOX

The state considers other markings of confidential in the bid/proposal document to be insufficient. The bidder/proposer agrees to hold the state harmless for any damages arising out of the release of any materials unless they are specifically identified above.

Section 5: Bidder Agreement: Piggybacking Purchasing Service/ State of Wisconsin Departments / UW System Universities Interested State Departments and/or other UW-System campuses:

· Will contact the contractor directly to place orders referencing the state agency contract number; and

· Are responsible for receipt, acceptance, and inspection of commodities directly from the contractor, and making payment directly to the contractor.

UW-Milwaukee is not party to these purchases or any dispute arising from these purchases and is not liable for delivery or payment of any of these purchases.

Bidders/Proposers may or may not agree to furnish the commodities or services of this bid/proposal to Wisconsin State Departments and UW System Univerisities. A vendor’s decision on participating in these services has no effect on awarding this contract.

Bidder: Please indicate your willingness to furnish the commodities or services to Wisconsin State Departments, and UW System Universities by checking the appropriate box below.

FORMCHECKBOX

I Agree to furnish the commodities or services of this bid/proposal to State of Wisconsin Departments with any special conditions noted below.

FORMCHECKBOX

I Do Not Agree to furnish the commodities or services to State of Wisconsin Departments.

FORMCHECKBOX

I Agree to furnish the commodities or services of this bid/proposal to UW System Universities with any special conditions noted below.

FORMCHECKBOX

I Do Not Agree to furnish the commodities or services to UW System Universities.

Special Conditions (if applicable):

Section 6: Bidder Identification (Check all that apply)

FORMCHECKBOX

We claim minority bidder preference [Wis. Stats.16.75(3m)(b)(3)]. Under Wisconsin Statutes, a 5% preference may be granted to CERTIFIED Minority Business Enterprises. Bidder must be certified by the Wisconsin Supplier Diversity Program. If you have questions concerning the certification process, contact the Wisconsin Supplier Diversity Program, 6th Floor, 101 E. Wilson St., Madison, WI 53703, (608) 267-9550. Does Not Apply to Printing Bids.

FORMCHECKBOX

We claim disabled veteran owned business bidder preference [Wis. Stats.16.75(3m)(b)(3)]. Under Wisconsin Statutes, a 5% preference may be granted to CERTIFIED Disabled Veteran Owned Businesses. Bidder must be certified by the Wisconsin Supplier Diversity Program. If you have questions concerning the certification process, contact the Wisconsin Supplier Diversity Program, 6th Floor, 101 E. Wilson St., Madison, WI 53703, (608) 267-9550. Does Not Apply to Printing Bids.

FORMCHECKBOX

We are a work center certified under Wis. Stats. S. 16.752 employing persons with severe disabilities. Questions concerning the certification process should be addressed to the Work Center Program, State Bureau of Procurement, 6th Floor, 101 E. Wilson St., Madison, WI 53703, (608) 266-5462.

Section 7: Bidder Certifications

Wis. Stats. s. 16.754 directs the state to purchase materials which are manufactured to the greatest extend in the United States when all other factors are equal. Materials covered in our bid were manufactured in whole or in substantial part in the United States. FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown

FORMCHECKBOX

We certify that we have not, either directly or indirectly, entered into any agreement or participated in any collusion or otherwise taken any action in restraint of free competition, that no attempt has been made to induce any other person or firm to submit or not to submit a bid, that this bid has been independently arrived at without collusion with any other bidder, competitor or potential competitor; that this bid has not been knowingly disclosed prior to the opening of bids to any other bidder or competitor; that the above statement is accurate under penalty of perjury.

FORMCHECKBOX

We certify that we are not currently engaged in a boycott of the State of Israel. Should we be awarded a contract, we understand that future engagement in a boycott of the State of Israel may result in contract termination.

FORMCHECKBOX

We will comply with all terms, conditions and specifications required by the state in this Request for Bid/Proposal and all terms of our bid.

Section 8: Bidder Signature

Name of Authorized Company Representative:

Title:

Phone:

Fax:

Signature of Above

Date:

Email:

This document can be made available in alternate formats to individuals with disabilities upon request.