N4008519R9124_Contractor_Information_Form.docx

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New River Ambulatory Care Center/Dental Clinic Replacement
Solicitation number
N4008519R9124
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SOURCES SOUGHT – CONTRACTOR INFORMATION FORM

Use this form to provide contractor’s general information. Please limit response to one page. The box at the bottom of this form may be used to clarify any requested information.

1. Contractor Information:
DUNS:
CAGE Code:
Firm Name:
Address:
Name of POC for firm:
Phone Number of POC:
Email of POC:

2. Type of Business: (check all that apply)

|_| SBA certified 8(a) firm
|_| SBA certified HUBZone Small Business

|_| Service-Disabled Veteran-Owned Small Business

|_| Veteran Owned Small Business

|_| Woman Owned Small Business

|_| Economically Disadvantaged Women-Owned |_| Small Business Small Business

3. Bonding Capacity:

Surety Name:
Maximum bonding capacity per project:
$
Aggregate maximum bonding capacity:
$

4. This space may be used to provide any additional information to clarify the above items only:

Please DO NOT change content of the form

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