Response Form A~52.docx

RESPONSE FORM A

RFR # 25-TOX-L85

COMMBUYS # BD-24-1084-POLCL-25100-101701

Before submitting this and all other forms associated with this solicitation, all Bidders are advised to check the solicitation record on www.COMMBUYS.com for the final versions of all forms.

All Bidders must complete and return this Attachment with their response in order to be considered responsive. Completing every section of this document fully is mandatory unless instructions for specific questions state otherwise.

Company name

Street address, city, state, zip

Main phone number

Toll-free phone number

Fax number

Website

Name, Title

Phone number

Fax

Email

Section 2. Checklist of Required Documentation Omission of required information or documentation may be grounds for Bidder disqualification. To ensure accurate review of your submission, please follow the file naming conventions and use the provided wording for the “Response Description” field.

File name: Response Form A_[your company name] Response description: Response Form A

File name: Bidder Price File_[your company name] Response description: Bidder Price File

Response description: Bidders must check the box to the right to signify agreement and understanding.

Response description: Bidders must check the box to the right to signify agreement and understanding.

N/A

File name: SCF_[your company name] Response description: Standard Contract Form

Contractor Authorized Signatory

Complete electronically and submit with response.

File Name: Auth_Sig_[your company name] Response description: Contractor Authorized Signatory

File Name: Bidder _Ref _[your company name] Response description: Business Reference Form

File Name: PPD_[your company name] Response description: Prompt Pay Discount Form

File Name: EPP_[your company name] Response description: EPP Form

File Name: SDP_ [your company name] Response description: Supplier Diversity Form

Company Information:

Basic Information

Use this column for the answer or attach additional documentation

Number of years in business prior to the due date of this solicitation

Has the company had a previous Tax ID? What was the company’s past name?

Was this the result of a merger or acquisition? Please define with the dates of this circumstance.

Number of years in business offering each service that that your company is submitting a response.

Corporate Headquarters location.

Business hours/days

Insurance. Describe your company’s liability (general and auto), property, personal injury and worker’s compensation insurance, including the limits, in the box below. Submit certified copies of insurance.

General liability

Auto

Worker’s Compensation

Professional Liability

Personal injury

(Other)

Financial Stability Litigation, Penalties, Pending Actions, Enforcement Actions, or Bankruptcy: The bidder shall submit a description of any and all investigations, indictments or pending litigation by any federal, state or local jurisdiction relating to the bidder, any officer, director, partner or member thereof, any affiliate or any related company. A list of all criminal convictions within the last five years relating to the bidder, any officer, director, partner or member thereof, any affiliate or any related entity. A list of all civil penalties, judgments, consent decrees and other sanctions within the last five years, as a result of any violation of any law, rule, regulation or ordinance in connection with its business activities relating to the bidder, any officer, director, partner or member thereof, any affiliate or any related entity. A list of all actions occurring within the last five years which have resulted in revocation or suspension of any permit or authority to do business in any jurisdiction relating to the submitting entity, any officer, director, partner or member thereof, any affiliate or any related entity. A list of all actions occurring within the last five years that have resulted in the barring from public bidding relating to the bidder, an officer, director, partner or member thereof, any affiliate or any related entity. A list of all pending actions and enforcement actions, including OSHA violations. A list of all bankruptcy and other similar proceedings within the past five years relating to the bidder, any officer, director, partner or member thereof, any affiliate or any related entity.

Defaults: The bidder shall provide a description, in detail, of any situation in which the bidder’s firm (either alone or as part of a joint venture), or a subsidiary of the bidder’s firm, defaulted or was deemed to be in noncompliance of any contractual obligations, explaining the situation, its outcome and all other relevant facts associated with the event described. Please also provide the name, title and telephone number of the principal manager of the contract user who asserted the event of default or noncompliance.

Other Adverse Situations: The bidder shall provide a description of any present facts known to the bidder that might reasonably be expected to affect adversely either its ability to perform any aspect of the agreement or the viability of any affiliated entity that might reasonably be expected to supply financial support.

Use this column for the answer

Describe any Litigation, Penalties, or Bankruptcy

Describe any Defaults

Describe any other Adverse Conditions

Describe any actions, pending actions, enforcement actions or violations

Subcontractor Disclosure. Please copy and paste additional copies of the table below for more subcontractors. Each subcontractor is subject to individual SST approval.

Company name

Street address, city, state, zip

Main phone number

Toll-free phone number

Fax number

Website

Products / Services this Subcontractor intends to provide under the Contract (if approved)

Value Added Services (for all categories). Please describe any value-added services provided by your company that are relevant to the scope of your response to this RFR. Limit: 1 page.

Use the box below for the answer

Certification

I , ___________________________________, agree to all terms, conditions and requirements stated in this RFR. I realize failure to comply with any requirement of this RFR after contract award may result in termination of an awarded contract.

Signed electronically Authorized officer name:

Title:

Date: