OMESformCP076.pdf
PDF 286 KB Posted
- Attached to
- RFI for Biosimilar Insulin Production
- Solicitation number
- EV00000959
- Issued by
- Oklahoma
About this file
This is a Responding Bidder Information form (OMES Form CP076) issued by the Oklahoma Central Purchasing office for use with the Request for Information (RFI) for Biosimilar Insulin Production from the Oklahoma State Department of Health (OSDH). Bidders responding to this RFI must complete this certification form and submit it along with their solicitation response. The form requires bidders to provide general company information including FEIN/SSN, Supplier ID, company name, contact information, address, phone, email, website, and fax number.
The form includes several mandatory certifications and disclosures that bidders must address. Bidders must declare whether they are engaged in a boycott of goods or services from Israel, confirm registration status with the Oklahoma Secretary of State (or provide an exemption statement), and provide proof of workers' compensation insurance coverage or submit a signed statement claiming exemption under Oklahoma statute. Additionally, bidders may elect to identify themselves as a service-disabled veteran business enterprise and, if claiming such status, must provide supporting documentation including federal certification of service-disabled veteran status, verification of at least 51% ownership by service-disabled veterans, and evidence that one or more service-disabled veterans control the management and daily operations. An authorized representative must sign and date the form to certify the accuracy of the information provided.
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Other files
| File | Type | Posted |
|---|---|---|
| RFI_Questions_SB1344_Insulin_Affordability.pdf |
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Text version
OMES Form CP076 (11/2024) RESPONDING BIDDER INFORMATION | Page 1 of 1
Central Purchasing
RESPONDING BIDDER INFORMATION
You must submit a Certification for Competitive Bid and Contract along with the response to the solicitation.
1. SOLICITATION
Solicitation #
2. BIDDER GENERAL INFORMATION
FEIN/SSN Supplier ID
Company name
3. BIDDER CONTACT INFORMATION
Address
Contact name Title
Email Phone Website Fax
4. BIDDER IS ENGAGED IN BOYCOTT OF GOODS OR SERVICES FROM ISRAEL
Yes No
5. REGISTRATION WITH THE OKLAHOMA SECRETARY OF STATE
Yes Filing number:
No Prior to the contract award, the successful bidder is required to register with the Secretary of State or must attach a signed statement that provides specific details supporting the exemption the supplier is claiming (sos.ok.gov or 405- 521-3911).
6. WORKERS’ COMPENSATION INSURANCE COVERAGE
Bidder is required to provide a certificate of insurance showing proof of compliance with the Oklahoma Administrative Workers’ Compensation Act.
Yes Include a certificate of insurance with the bid.
No Exempt from the Administrative Workers’ Compensation Act pursuant to 85A O.S. § 2(18)(b)(1-11). (Attach a written, signed and dated statement on letterhead stating the reason for the exempt status. For frequently asked questions concerning workers’ compensation insurance, visit wcc.ok.gov.)
7. DISABLED VETERAN BUSINESS ENTERPRISE ACT
Yes I am a service-disabled veteran business as defined in 74 O.S. § 85.44E.
Include the following with the bid response:
1. Certification of service-disabled veteran status as verified by the appropriate federal agency.
2. Verification of not less than 51% ownership by one or more service-disabled veterans.
3. Verification of the control of the management and daily business operations by one or more service-disabled veterans.
No I do not meet the criteria as a service-disabled veteran business.
8. SIGNATURE
Authorized signature Date
Name Title https://www.sos.ok.gov/ https://www.wcc.ok.gov/
| Central Purchasing |
| RESPONDING BIDDER INFORMATION |
| Solicitation: |
| FEINSSN: |
| Supplier ID: |
| Company name: |
| Contact name: |
| Title: |
| Email: |
| Phone: |
| Website: |
| Fax: |
| 4 BIDDER IS ENGAGED IN BOYCOTT OF GOODS OR SERVICES FROM ISRAEL: Off |
| Prior to the contract award the successful bidder is required to register with the Secretary of State or must attach a: Off |
| Compensation Act: Off |
| 7 DISABLED VETERAN BUSINESS ENTERPRISE ACT: Off |
| Date: |
| Name: |
| Title_2: |
| Filing number: |
| Address: |
File details come from the government source that posted it. Updated .