MANUFACTURER CERTIFICATION Form.pdf

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Administrative Services Division - Purchasing Unit

NEW YORK STATE DEPARTMENT of TRANSPORTATION

MANUFACTURER’S CERTIFICATION FORM

INSTRUCTIONS TO BIDDERS:

This “Manufacturer’s Certification” is to be forwarded to the manufacturer by the bidder (if required by

IFB), completed by the manufacturer and returned to the bidder by the manufacturer, and submitted with the bidder’s offer. (See “QUALIFICATION OF BIDDER” clause).

BIDDER’S COMPANY NAME: ______________________________________________

STREET ADDRESS: _______________________________________________________

CITY, STATE ZIP: ________________________________________________________

List the Products/Components to which this Certificate applies: ___________________________________________

The manufacturer executing this certification by signature below does hereby attest to the accuracy and validity of the responses to the following questions:

1. Is the bidder listed above an authorized dealer? Yes No

2. Do you as a manufacturer agree to supply the bidder/dealer with all quantities of products ordered pursuant to any resulting contract with the State? Yes No

3. Do you as a manufacturer certify that product listed above meets the requirements stated in the IFB? Yes No

MANUFACTURER’S COMPANY NAME:

ADDRESS:

TELEPHONE NUMBER:

FAX NUMBER:

E-MAIL ADDRESS:

PRINTED OR TYPED COPY OF SIGNATURE

SIGNATURE OF AUTHORIZED DATE

MANUFACTURER’S REPRESENTATIVE

TITLE

Contract/Procurement