F105900345_14AttachmentGBusinessReferenceForm.pdf
PDF 146 KB Posted
- Attached to
- Statewide Claims and Investigation Services
- Solicitation number
- ITN-00141
- Issued by
- Leon County, Florida
About this file
This document is a Business Reference Form included as Attachment G in an Invitation to Negotiate (ITN) issued by the Florida Department of Financial Services, Division of Risk Management, for Statewide Claims and Investigation Services. The ITN solicits competitive sealed Responses from qualified vendors interested in providing these services statewide. The ITN has undergone several addendums extending deadlines and clarifying definitions. The contract term and any renewal options are not specified.
The Business Reference Form is to be completed by entities that have a business relationship with the Respondent, such as a subcontractor or customer, to provide an evaluation of the Respondent's performance. The form requires the reference to certify they do not have a conflict of interest. The ITN will be administered through the Florida Vendor Bid System, and failure to file a protest within the prescribed timeframe constitutes a waiver of proceedings under Chapter 120 of the Florida Statutes.
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Text version
[Completion of this form may be requested during the Negotiation Phase of the ITN.]
DEPARTMENT OF FINANCIAL SERVICES
Business Reference Form
Attachment G
This business reference is for (Respondent’s Name):
The Respondent shall require its references to complete the form below. References should be directly relevant to the services in the solicitation.
This form must be completed by the person giving the reference for the Respondent named above. The Respondent is submitting a reply to a procurement. For purposes of this form, the Respondent is a business entity that currently or has previously provided services to your organization.
Upon completion of this form, please return the original to the Respondent.
REFERENCE INFORMATION
Organization Name: Phone #: ( ) - Reference Name: Title:
BUSINESS RELATIONSHIP WITH RESPONDENT
Relationship to Respondent: (e.g., subcontractor, customer). Years of Relationship:
Dates:
If a customer, please describe the primary service the Respondent provides your organization:
Respondent acted as:
primary provider or subcontractor or
N/A
Do you have a business or professional interest in the Respondent’s organization?: Yes or No
If yes, please describe:
PERFORMANCE OF RESPONDENT
Have you experienced any performance problems with the Respondent’s organization?: Yes or No If yes, please describe:
As the person authorized to sign this form, I certify that the above information is correct. I also certify that I am not:
• a current employee of the Department;
• a former employee of the Department, within the past three (3) years;
• a person currently or formerly employed by the Respondent’s organization;
• a board member of the Respondent’s organization; or
• a relative of any of the above.
I further certify that:
• the business organization that I work for is not based solely in a foreign country; and
• a member of the Respondent’s organization, has not written and/or otherwise completed this form on my behalf.
Reference’s Signature Date
Reference Name
2122-01 ITN RM Statewide Claims and Investigation Services
Rev. 04/05/18
| DEPARTMENT OF FINANCIAL SERVICES |
| This business reference is for (Respondent’s Name): |
| Reference’s Signature Date |
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