ITB480 Medical Gases & Equipment - Cover Form.pdf

ITB480 Medical Gases & Equipment

ATTACHMENT 6 - COVER FORM

(M) Attachment 6, Cover Form must be completed, signed, and uploaded to the Questions page in IPRO. Failure to complete and submit this form may result in your Bid being deemed non-responsive.

Instructions: The Bid must include a signed copy of this cover form. Copy and paste this form onto your company letterhead, or include the following information: Bidder’s company name, mailing address, phone number, fax number, e-mail address, and name of Bidder’s authorized signer. The Cover Form must include the ITB Number and Title and must be signed by an individual authorized to commit the Bidder to the contents of the Bid.

Requirement Response Bidder’s corporate or other legal entity status ☐ Corporation

☐ Limited Liability Corporation (LLC) ☐ Limited Liability Partnership ☐Sole Proprietorship ☐ Other (specify)

Bidder’s Tax Identification Number

EIN:

Bidder’s DUNS Number

DUNS:

Is Bidder a legal entity with the legal right to contract?

☐ Yes ☐ No

Other than modifications/exceptions identified on Attachment 2, in compliance with Section 3 of this ITB, does Bidder accept, and is Bidder willing to comply with, the requirements of this ITB?

Is Bidder in compliance with applicable equal employment regulations?

Does Bidder affirm that it has not employed any company or person other than a bone fide employee working solely for the Bidder or a company regularly employed as its marketing agent, to solicit or secure the Contract, and that it has not paid or agreed to pay any company or person, other than a bone fide employee working solely for the Bidder or a company regularly employed by the Bidder as its marketing agent, any fee, commission, percentage, brokerage fee, gifts, or any other consideration contingent upon or resulting from the award of the Contract?

Does Bidder understand and agree that for breach or violation of the above term, the State has the right to annul the Contract without liability or, in its discretion, deduct from the offered price the amount of any such fee, commission, percentage, brokerage fee, gifts, or contingencies?

Firm(s) and/or staff responsible for writing the Bid?

Names:

Does Bidder affirm that it is not currently suspended, debarred, or otherwise excluded from federal or state procurement and non-procurement programs?

Note: vendor information is available at https://sam.gov.

Does the Bidder affirm that the Bid will be firm and binding for ninety (90) calendar days from the Bid opening date?

https://sam.gov/

Does Bidder warrant that it does not knowingly and willfully employ persons who cannot legally work in this country; and that Bidder takes steps to verify that it does not hire persons who have entered our nation illegally or cannot legally work in the United States; and that any misrepresentation in this regard or any employment of persons who have entered our nation illegally or cannot legally work in the United States constitutes a material breach and will be cause for the imposition of monetary penalties up to five percent (5%) of the Bid price, per violation, and/or termination of the Contract?

Signed By:

Printed Name:

Date:

ATTACHMENT 6 - COVER FORM