EXHIBIT D- Contract Signature Page.pdf
PDF 139 KB Posted
- Attached to
- Road-Killed Deer Removal and Disposal
- Solicitation number
- 3520T01
- Issued by
- Pennsylvania
About this file
This document is an Exhibit D - Contract Signature Page for the Pennsylvania Department of Transportation's (PennDOT) Invitation to Qualify (ITQ) #3520T01 for "Road-Killed Deer Removal and Disposal" services. The contract is for the removal and lawful disposal of dead deer from PennDOT's right-of-ways, highways, and interchanges throughout the Commonwealth of Pennsylvania. Initial enrollments are due by June 22, 2021, and applications will continue to be accepted until January 31, 2031. The document outlines the required signatures, certifications, and contact information for the contractor.
The contract requires the contractor to provide the requested services upon receiving orders from the agency. The contractor must complete the signature page in ink or type, provide contact information, and indicate if they are a Minority-Owned or Woman-Owned Business Enterprise (MBE/WBE) certified by PennDOT. The document also requires approvals from various state agencies, including the PennDOT Office of Chief Counsel, the Office of the Comptroller, and the Office of the Attorney General.
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Text version
EXHIBIT D
CONTRACT SIGNATURE PAGE
EXHIBIT D
CONTRACT SIGNATURE PAGE
ITQ # 3520T01, “Road-Killed Deer Removal and Disposal”
(Complete in INK or TYPE only – DO NOT use pencil)
CONTRACTOR MUST COMPLETE ALL APPLICABLE AREAS
PHONE NUMBER: FAX NUMBER:
CORPORATION: President, Vice President, Chief Operating Officer (COO), Chief Executive Officer (CEO) or the Chairperson of the Board of Directors
SIGNATURE
SOLE PROPRIETORSHIP:
OWNER ONLY:
SIGNATURE
PARTNERSHIP:
ONE GENERAL PARTNER ONLY
SIGNATURE
LIMITED LIABILITY CO.:
MEMBER OR MANAGER
SIGNATURE
SIGNATURE DATE SIGNATURE DATE
SIGNATURE DATE SIGNATURE DATE
SIGNATURE DATE
CONTRACTOR NAME AND ADDRESS
If SOLE PROPRIETOR is doing business as (d/b/a) or trading as (t/a) another name, indicate such Example John Brown d/b/a or t/a Brown’s Deer Removal and Disposal)
CONTRACTOR CONTACT PERSON:
1 AGENCY HEAD OR DESIGNEE
X_________________________________ ____________
CONTRACTOR’S SIGNATURE, DATE AND TITLE (required in INK)
Are you a MBE/WBE certified by PennDOT? Yes No If yes, Certification Number:
E-MAIL ADDRESS:
In compliance with the Invitation to Qualify (ITQ) and subject to Exhibit B “Special Contract Terms and Conditions”, Exhibit A, “Standard Contract Terms and Conditions” and any documents attached to the ITQ or incorporated by reference, the undersigned offers and agrees, if this application is accepted, to furnish any and all services upon which it receives orders. The undersigned acknowledges that the representations made in this application are material and important and shall be relied upon by the Commonwealth in awarding the Contract(s) for which the application is submitted. Any misstatement in this application is, and shall be treated as, fraudulent concealment from the Commonwealth of the facts relating to the submission of this application.
x_______________________________ _________ _______________________
DATE TITLE
x_______________________________ _________ _______________________
DATE TITLE
x_______________________________ _________ _______________________
TAX ID# (FIN):
SAP VENDOR #:
4 GENERAL COUNSEL (Approved as to Legality and Form) x_______________________________ _________ _______________________
DATE TITLE
DATE TITLE
5 ATTORNEY GENERAL (Approved as to Legality and Form)2 PENNDOT OFFICE OF CHIEF COUNSEL (Approved as to Legality and Form)
X_________________________________ ____________
X_________________________________ ____________
X_____________________________ __________
X_____________________________ __________
3 OFFICE OF THE COMPTROLLER (Approved as to Fiscal Responsibility, Budgetary Appropriateness and Availability of Funds)
CONTRACT EXECUTION DATE
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