J12_-_EEOC_Clearance_Request_Info.pdf

Attachment J-12: DOL EEOC Clearance Request Information

DOL EEOC Clearance Request Information

VENDOR IDENTIFICATION Prime

Contractor

Yes No Subcontractor Yes No

Full name of vendor:

Central Contractor Registration (CCR) Cage Code: DUNS number

Vendor name as it appears in CCR:

Physical address as it appears in CCR:

CONTRACT PERFORMANCE List place(s) of performance with reference to subject proposed work

Place(s) of Performance: Number of employees at this site:

Previous Government contracts performed from this site:

Yes No

Yes No

Yes No

Yes No

POINT OF CONTACT

Point of contact for DOL EEOC clearance issues

Name and title

Telephone and fax numbers

Email address

PROPOSED AWARD AMOUNTS

List proposed award amounts

Base year $ Option year five $

Option year one $ Option year six $

Option year two $ Option year seven $

Option year three $ Option year eight $

Option year four $ Option year nine $

Total base plus all option periods award amount $

CORPORATE AFFILIATES List the name, address, POC and telephone number of all corporate affiliates

1 4

2 5

3 6