Att_11_OFCCP_EEOC_Clrnc_Req.pdf

FA4600-16-R-0012

Attachment 11

DOL OFCCP EEOC Clearance Request Information Form Complete for each vendor with prime or subcontractor status in subject proposal

VENDOR IDENTIFICATION Prime

Contractor Yes No Subcontractor Yes No

Full name of vendor:

System for Award Management (SAM) Cage Code: DUNS number Vendor name as it appears in SAM:

Physical address as it appears in SAM:

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 three $ Option year one $ Option year four $ Option year two $ Six-month Extension $

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