Ex B Contractor Info Fillable.pdf

EXHIBIT B – CONTRACTOR INFORMATION

to be submitted with Response

CONTRACTOR (LEGAL NAME OF ENTITY)

ADDRESS FOR THE PRINCIPLE PLACE OF BUSINESS

CITY, STATE, ZIP:

TELEPHONE

STRUCTURE (CORPORATION, PARTNERSHIP, SOLE PROPRIETORSHIP, ETC.)

YEAR ESTABLISHED

FEDERAL EMPLOYER ID

WASHINGTON UBI (REVENUE REGISTRATION NUMBER)

NAME, TITLE, ADDRESS, EMAIL, PHONE, AND FAX NUMBERS FOR CONTRACTOR’S RFP CONTACT.

NAME AND TITLE

ADDRESS:

CITY, STATE, ZIP

PHONE:

FAX:

E-MAIL

PRINCIPLE OFFICERS (E.G.: PRESIDENT, VICE PRESIDENT, TREASURER, BOARD CHAIRPERSON)

NAME TITLE EMAIL ADDRESS

CONTRACTOR'S EMPLOYEE RELATIONSHIP TO STATE OF WASHINGTON

If the Contractor or any party named above was, or is, an employee of WA State during the past 24 months, the following information is required: If none, indicate “not applicable”.

NAME AGENCY TITLE SEPARATION DATE

PERSONS EMPLOYED BOTH BY CONTRACTOR AND STATE OF WASHINGTON

Contractors employing or having on their governing board as of the date of their proposal, WA State employees, or former WA State employees, shall identify such persons and their position and responsibilities within the Contractor’s organization. If none, indicate “not applicable”.

NAME AGENCY TITLE SEPARATION DATE (OR N/A)

Responsibilities:

Responsibilities: