Fill-in Certification QSDM--J8-100437-N.docx

QSDM-J8-100437-N

Fill-in Self Certification

This is an extra effort designed to ensure no mistakes in offer have been made. Please review your offer and verify its accuracy and exact compliance with the descriptions as stated in the RFP.

In the event your firm ships an item that does not meet the specifications in the IPD, your firm will be responsible for a refund of the payment, or a correct replacement item and any cost incurred by the government.

___ I have reviewed the description as stated in the RFP. The items we intend to offer meet the description exactly as stated in the RFP.

Company name__________________________________

Signature _______________________________________ Date _________

Acknowledgement of Past Performance Questionnaire

This solicitation contains a Past Performance Questionnaire. This is to be sent to three of your customer’s (other than GSA) and they in turn will complete the form and submit it back to the GSA Contract Specialist, Sean Dugan. The results of this will be used to evaluate past performance by your company for similar type items and contract value over the last three years. If you do not have three customers who meet this requirement, please indicate by circling the number of customers that you have sent the questionnaire to.

___ I have submitted this questionnaire to (one) (two) (three) customers who have experience providing similar type items and contract value over the last three years. The completed copies of the questionnaire will be submitted to the GSA Contract Specialist by the time and date indicated.

___ I do not have three customers who have experience providing similar type items and contract value over the last three years.

Signature _______________________________________ Date _________