ESBD_File_343792_Exhibit C Bid Execution Page.pdf

Exhibit C – Bid Execution Page 03/14/2022

Exhibit C – Bid Execution Page

TEXAS HEALTH AND HUMAN SERVICES COMMISSION

Solicitation No.: Solicitation Post Date: Response Due Date: Response Due Time:

HHS0014177 November 30, 2023 December 14, 2023 10:30 A.M.

By submitting the Response, Respondent represents and warrants that the individual submitting this document and the documents made part of this Response is authorized to sign such documents on behalf of the Respondent and to bind the Respondent under any contract that may result from the submission of the Response. Respondent agrees to comply with all Contract Affirmations, Data Use Agreement, and Uniform Terms and Conditions – Vendor which are attached and incorporated into this document.

Check below if preference claimed under Texas Administrative Code (TAC), Title 34, Part 1, Chapter 20, Subchapter D, Division 2, Rule §20.306:

□ Goods produced or offered by a Texas bidder that is owned by a Texas resident service-disabled veteran

□ Goods produced in Texas or offered by a Texas bidder that is not owned by a Texas resident service-disabled veteran

□ Agricultural products grown in Texas

□ Agricultural products offered by a Texas bidder

□ Services offered by a Texas bidder that is owned by a Texas resident service-disabled veteran

□ Services offered by a Texas bidder that is not owned by a Texas resident service-disabled veteran

□ Texas Vegetation Native to the Region

□ USA produced supplies, materials or equipment

□ Products of persons with mental or physical disabilities

□ Products made of recycled, remanufactured, or environmentally sensitive materials including recycled steel

□ Energy Efficient Products

□ Rubberized asphalt paving material

□ Recycled motor oil and lubricants

□ Products produced at facilities located on formerly contaminated property

□ Products and services from economically depressed or blighted areas

□ Vendors that meet or exceed air quality standards

□ Recycled or Reused Computer Equipment of

Other Manufacturers

□ Foods of Higher Nutritional Value.

RESPONDENT MUST COMPLETE ALL ITEMS:

X Signature of Vendor or Authorized Representative (Must be signed; failure to sign may disqualify response.)

Print Name:

Texas Vendor ID No. (or Federal Employer’s ID):

Name of Business:

Street Address:

City-State-Zip Code:

Telephone Number:

Fax Number:

E-Mail Address:

24-Hour Contacts – Must list a minimum of 2:

Contact 1

Name Phone Email

Contact 2 Name Phone Email

By signing this bid, bidder certifies that if a Texas address is shown as the address of the bidder, bidder qualifies as a Texas Bidder as defined in Tex. Gov’t Code § 2155.444(c)(2)

Exhibit C – Bid Execution Page