Exhibit A-2_Bidders Profile.docx

EXHIBIT A-2 – BIDDER’S PROFILE

Type/print full legal name of Bidder

BIDDER INFORMATION

Legal name of Bidder:

Address of Bidder:

Note: This information must match the information from Bidder’s Business License.

Business Name Address City, State, Zip Code

Bidder’s Washington State Department of Revenue Registration Number/Unified Business Identifier (UBI) Number:

Note: A nine-digit UBI number is assigned to each registered businesses in Washington.

Taxpayer Identification No. (TIN):

Note: Your TIN will be either a number issued by the IRS (e.g., Employer Identification Number, Federal Tax Identification Number) or a number issued by the Social Security Administration (i.e., your Social Security Number). Do Not provide a Social Security Number.

Does Bidder intent to utilize subcontractors to perform the Contract, if awarded?

Note: If Bidder intends to utilize subcontractors, Bidder must identify Bidder’s intended subcontractors.

Yes |_| No |_| If yes, provide Bidder’s anticipated subcontractor(s): ____________

If yes, provide Bidder’s MWBE certification no.: ____________

Is your firm a self-certified Washington State Small Business?

Note: See Exhibit A-1 – Bidder’s Certification for criteria to qualify as a Washington State Small Business.

Note: Regardless of size, a qualifying business must be owned and operated independently from all other businesses. In regard to size, the gross revenue thresholds, as reported on Bidder’s tax returns, are as follows:

· Microbusiness: Annual gross revenue of less than one million dollars.

· Minibusiness: Annual gross revenue of more than one million dollars, but less than three million dollars.

· Small Business: Annual gross revenue of less than seven million dollars over each of the three prior consecutive years.

Yes |_| No |_| If yes, provide the location for Bidder’s principal place of business:

Street Address City, State, Zip Code If yes, what is your business size (based on annual gross revenue)?

Is your firm certified as a Veteran-Owned Business with the Washington State Department of Veteran Affairs?

Note: See Exhibit A-1 – Bidder’s Certification for criteria to qualify as a Certified Veteran-Owned Business.

Yes |_| No |_| If yes, provide Bidder’s WDVA certification no.: _____________

CONTRACT MANAGEMENT POINTS OF CONTACT FOR BIDDER

Authorized Representative Name:

Email:

Phone:

Contract Administrator Name:

Email:

Phone:

Address for Enterprise Services to send legal notices:

Company name:

Attn:

Address:

City/State/Zip:

Email: ________________

Signature Authority (if awarded a contract) Name:

Title:

ORDERING/SALES POINTS OF CONTACT (expand as necessary)

REFERENCES

Provide a minimum of three (3) commercial or government references for which bidder has delivered goods and/or services similar in scope as described in the Competitive Solicitation.

REFERENCE 1

Company Name:

Contact:

Phone:

Email:

REFERENCE 2

Company Name:

Contact:

Phone:

Email:

REFERENCE 3

Company Name:

Contact:

Phone:

Email:

Return this Bidder’s Profile to Procurement Coordinator at:

chase.johnson@wsdot.wa.gov EXHIBIT A-2 – BIDDER’S PROFILE: RFQQ 2025 0131– MEDICAL INVOICING REVIEW SERVICES PAGE 1 (Rev 2024-04-25) image1.png image2.jpeg