Exhibit C DQ Vendor Information-Confirmation of Offer Form.docx
DOCX document 40 KB Posted
- Solicitation number
- IFB1 FAAA 2017000182 2
- Issued by
- Denver County, Denver City, Colorado
About this file
This is a Vendor Information Form and Confirmation of Offer document issued by the Colorado Department of Public Health & Environment for Solicitation No. IFB FAAA 2017000182 regarding the procurement of syringes. The form serves as the official submittal document that vendors must complete and return to the Colorado Department of Public Health & Environment Contracts and Purchasing Unit at 4300 Cherry Creek Drive South, Denver, CO 80246-1530, with attention to Sam Fuller, Purchasing Agent. Responses must be clearly marked with the solicitation number, due date, and time on the outside of the submittal package and must arrive prior to the specified deadline.
The form requires vendors to provide essential business information including their Colorado VSS vendor customer number, Federal Employer's Identification Number (FEIN), DUNS number if applicable, company name and any doing-business-as (DBA) designations, complete address and contact information, and the typed or printed name and handwritten signature of an authorized company officer or agent. Vendors must also designate a point of contact for solicitation-related communications with associated contact details. The form includes a compliance question regarding acceptance of Colorado purchase order terms and conditions, which vendors must answer affirmatively or negatively. A signed original of this completed form must be submitted with the original solicitation response.
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Text version
Exhibit A
SOLICITATION NO: IFB FAAA 2017000182
TITLE: Syringes
Vendor Information Form & Confirmation of Offer
Responses must be clearly marked with SOLICITATION #, DUE DATE and TIME on the outside of the submittal. Responses submitted subject to the conditions stipulated herein and in accordance with the specifications set forth in the solicitation will be accepted at the address listed below prior to the submittal deadline.
RETURN SOLICITATION RESPONSE AND THIS FORM TO:
Colorado Department of Public Health & Environment Contracts and Purchasing Unit Mail Room (B1) 4300 Cherry Creek Drive South Denver, CO. 80246-1530 Attention: Sam Fuller, Purchasing Agent
PLEASE TYPE OR PRINT INFORMATION
VENDOR CUSTOMER # (From Colorado VSS):___________________________________________________________________
FEDERAL EMPLOYER’S IDENTIFICATION (FEIN) #: _______________________________________________________________
DUNS # (if applicable): ____________________________________________________________________________________
COMPANY NAME: ________________________________________ DBA (if applicable): ______________________________
ADDRESS: ______________________________________________________________________________________________
CITY, STATE, ZIP: _______________________________________________________________________________________
TYPED OR PRINTED NAME: _______________________________________________________________________________
HANDWRITTEN SIGNATURE OF AUTHORIZED COMPANY OFFICER / AGENT
SIGNING OFFICER / AGENT TITLE: _________________________________________________________________________
SIGNATURE DATE: ______________________________
E-MAIL ADDRESS: ______________________________________________________________________________________
PHONE #: __________________________________________ FAX #: ___________________________________________
POINT OF CONTACT FOR SOLICITATION-RELATED COMMUNICATIONS:
NAME______________________________________________ PHONE #: ______________________________________
E-MAIL: _____________________________________________________________________________________________
Do you accept Colorado PO Terms and conditions? Yes No
SUBMIT SIGNED ORIGINAL OF THIS FORM WITH ORIGINAL SOLICITATION RESPONSE
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