ExhibitA-2-BiddersProfile.pdf

EXHIBIT A-2 – BIDDER’S PROFILE: DOH25-014P –NITROGEN GENERATORS PAGE 1

(Rev 2024-04-25)

EXHIBIT A-2 – BIDDER’S PROFILE

Competitive Solicitation: No. DOH25-014P – Nitrogen Generators

Bidder: ___________________________ 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): ____________

EXHIBIT A-2 – BIDDER’S PROFILE: DOH25-014P –NITROGEN GENERATORS PAGE 2

BIDDER INFORMATION

Is your firm certified as a minority or woman owned business with the Washington State Office of Minority & Women’s Business Enterprises (OMWBE)?

Yes No

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.

Mini-business: 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)?

Microbusiness

Mini-business

Small Business

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:

EXHIBIT A-2 – BIDDER’S PROFILE: DOH25-014P –NITROGEN GENERATORS PAGE 3

CONTRACT MANAGEMENT POINTS OF CONTACT FOR BIDDER

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)

Name Phone Number E-mail Area of Responsibility

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:

REFERENCE 2

Company Name:

Contact:

REFERENCE 3

Company Name:

Contact:

EXHIBIT A-2 – BIDDER’S PROFILE: DOH25-014P –NITROGEN GENERATORS PAGE 4

WILL CALL/SERVICE LOCATIONS

Identify will call or service locations throughout the state.

LOCATION POINT OF CONTACT PHONE NUMBER AREA(S) OF RESPONSIBILITY

PURCHASE CARDS (I.E., CREDIT CARDS)

Please indicate which types of purchasing (credit) cards are accepted (note: any card fees must be included in the unit price of the bid):

Visa Master Card American Express Discover Other:

Return this Bidder’s Profile to Procurement Coordinator at:

bids@doh.wa.gov mailto:bids@doh.wa.gov