GSS25942-PENSION_IVV-appD.pdf

NON-COLLUSION STATEMENT

This is to certify that the undersigned Vendor has neither directly nor indirectly, entered into any agreement, participated in any collusion or otherwise taken any action in restraint of free competitive bidding in connection with this solicitation, and further certifies that it is not a sub-contractor to another Vendor who also submitted a bid/proposal as a primary Vendor in response to this solicitation submitted this date to the State of Delaware, Office of Management and Budget, Government Support Services.

It is agreed by the undersigned Vendor that the signed submission of this bid/proposal represents, subject to any express exceptions set forth on the Exception form, the Vendor’s acceptance of the terms and conditions of this solicitation including all specifications and special provisions.

NOTE: Signature of the authorized representative MUST be of an individual who legally may enter his/her organization into a formal contract with the State of Delaware, Office of Management and Budget, Government Support Services.

COMPANY NAME _________________________________________________________________________________________________________

NAME OF AUTHORIZED REPRESENTATIVE ____________________________________________________________

SIGNATURE TITLE

COMPANY ADDRESS

PHONE NUMBER FAX NUMBER

EMAIL ADDRESS _______________________________________________________________________________

FEDERAL E.I. NUMBER _____________________________________________________________________________

AFFIRMATION: Within the past five (5) years, has your firm, any affiliate, any predecessor company or entity, owner, Director, officer, partner or proprietor been the subject of a Federal, State, Local government suspension or debarment?

YES NO if yes, please explain:

THIS PAGE SHALL BE SIGNED AND NOTARIZED (NOTARY SEAL MUST BE VISIBLE) FOR YOUR

BID/PROPOSAL TO BE CONSIDERED.

SWORN TO AND SUBSCRIBED BEFORE ME this ________ day of , 20 __________

Notary Public: My commission expires:

City of: County of : State of :

VENDOR INFORMATION SHEET

COMPANY NAME: ________________________________________________________________________

DBA (if applicable): ________________________________________________________________________

Purchase Order Address: _____________________________________________________________________

Website: __________________________________________________________________________________

Diverse Vendor Self-Identification:

WBE MBE

VBE SDVBE IWDBE Other: ____________

State Certified: Yes No If yes, which State(s): _____________________________

Federal Certified: Yes No

Primary Contact Secondary Contact Contact Name Contact Type Phone Number/Ext.

Email Fax Number

Business Capability Statement:

(Provide a short capability statement about your business and its capabilities and skills to advertise who you are and what you do.)

BUSINESS REFERENCES

List a minimum of three business references of similar size and scope. Please do not list any State Employee(s) as a business reference. If Subcontractors are identified, a minimum of three business references must also be provided for each subcontractor.

REFERENCE ONE

Contact Name:

Cont ct Title:

Business Name:

Address:

Email:

Phone #:

Current Vendor (YES or NO):

Years Associated & Type of association:

Work Performed:

REFERENCE TWO

Contact Name:

Contact Title:

Business Name:

Address:

Email:

Phone #:

Current Vendor (YES or NO):

Years Associated & Type of association:

Work Performed:

REFERENCE THREE

Contact Name:

Contact Title:

Business Name:

Address:

Email:

Phone #:

Current Vendor (YES or NO):

Years Associated & Type of association:

Work Performed:

Contract No.: ________________________

Contract Title: ________________________________________________

CONFIDENTIALITY FORM

Responding vendor may elect to designate sections of their proposal as confidential, intellectual property, trade secrets, and other confidential business information. Vendor shall explain below how the redacted information is not “public record” as defined by 29 Del. C. § 10002. The State shall independently determine the validity of any vendor designation as set forth in this section. Any vendor submitting a bid/proposal herein expressly accepts the State’s absolute right and duty to independently assess the legal and factual validity of any information designated as confidential business information.

If your bid/proposal submission contains no redactions check the box below.

By checking this box, the Vendor acknowledges that they are not providing any information they declare to be confidential or proprietary for the purpose of production under 29 Del. C. Ch. 100, Delaware Freedom of Information Act.

Confidentiality and Proprietary Information

EXCEPTIONS FORM

Responding Vendors may elect to take minor exceptions to the terms and conditions of this solicitation. All exceptions must be submitted below.

Exceptions found elsewhere in the solicitation response will not be considered. __________________________________ maintains sole discretion to reject any exceptions.

If your submission contains no exceptions check the box below.

By checking this box, the responding vendor acknowledges that they take no exceptions to the specifications, terms or conditions found in this solicitation.

Paragraph # and Page #

Current Language Proposed Alternative Justification

Note: Use additional pages as necessary, but the format shall be the same as provided above.

SUBCONTRACTOR INFORMATION

PROPOSING VENDOR INFORMATION

Contract Number:

Proposing Vendor Name:

Mailing Address:

SUBCONTRACTOR INFORMATION

Subcontractor Name:

Mailing Address:

Diverse Vendor Self-Identification:

WBE MBE VBE SDVBE IWDBE Other

State Certified: Yes No If yes, which State(s):

Federal Certified: Yes No

DESCRIPTION OF WORK BY SUBCONTRACTOR

Name of the person signing (Proposing Vendor):

Title of the person signing:

Signature: ________________________________________ Date:

ACKNOWLEDGEMENT BY SUBCONTRACTOR

Name of the person signing:

Title of the person signing:

Signature: ________________________________________ Date: