rfb-dncr-2026-07.pdf

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THE STATE OF NEW HAMPSHIRE

DEPARTMENT OF NATURAL AND CULTURAL RESOURCES

REQUEST FOR BID FOR THE 2025 PEABODY “YELLOW ROOM” CARPET PROJECT (SUPPLY/INSTALL)

PURPOSE:

The purpose of this bid invitation is to establish a contract for supply and installation of commercial-grade tile carpeting to the State of New Hampshire with product list and requirements indicated in the SCOPE OF WORK and OFFER sections of this bid invitation, in accordance with the requirements of this bid invitation and any resulting contract. All work shall be completed in a reasonable time frame as mutually agreed upon with agency and vendor.

INSTRUCTIONS TO VENDOR:

Read the entire bid invitation prior to filling it out. Complete the pricing information in the “Offer” section (Detailed information on how to fill out the pricing information can be found in the “Offer” section); complete the “Vendor Contact Information” section; and finally, fill out, sign, and notarize page one of the bid invitation.

BID CONTACT:

Name: Jace Wirth State of New Hampshire Department of Natural and Cultural Resources Cannon Mountain Division of Parks and Recreation 260 Tramway Drive Franconia, New Hampshire 03580 Telephone: 603-823-7722 x750 Email: jace.c.wirth@dncr.nh.gov

BID SUBMITTAL:

All bids shall be submitted on this form (or an exact copy), shall be typed or clearly printed in ink, and shall be received on or before the date and time specified on page 1 of this bid under “Bid Closing”. Interested parties may submit a bid to the State of New Hampshire Department of Natural and Cultural Resources by email to:

jace.c.wirth@dncr.nh.gov. All bids shall be clearly marked with bid number and date due.

BID INQUIRIES:

Any questions, clarifications, and/or requested changes shall be submitted by an individual authorized to commit their organization to the Terms and Conditions of this bid and shall be received in writing at the no later than 2:00 PM on the date listed in the timeline below. Questions shall not be submitted to anyone other than the BID CONTACT or his/her representative. Bidders that submit questions verbally or in writing to any other State entity or State personnel shall be found in violation of this part and may be found non-compliant.

Submissions shall clearly identify the bid Number, the Vendor’s name and address and the name of the person submitting the question.

BID DUE DATE:

All bid submissions shall be received at the Department of Natural and Cultural Resources no later than the date and time shown on the transmittal letter of this bid. Submissions received after the date and time specified shall be marked as “Late” and shall not be considered in the evaluation process.

All offers shall remain valid for a period of one hundred eighty (180) days from the bid due date. A vendor’s disclosure or distribution of bids other than to DAS, Bureau of Purchase and Property may be grounds for disqualification.

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ADDENDA:

In the event it becomes necessary to add to or revise any part of this bid prior to the scheduled submittal date, the NH Bureau of Purchase and Property shall post any Addenda on their web site. Before your submission and periodically prior to the RFB closing, Vendors are required to check the site for any addenda or other materials that may have been issued affecting the bid. The web site address is https://das.nh.gov/Purchasing/vendorresources.asp.

TIMELINE:

The timeline below is provided as a general guideline and is subject to change. Unless stated otherwise, consider the dates below a “no later than” date.

09/04/2025: Bid Solicitation distributed on or by 09/16/2025: 2:00 PM (EST) Mandatory site visit for all bidders, Peabody Lodge

09/22/2025: Last day for questions, clarifications, and/or requested changes to bid 09/26/2025: 2:00 PM (EST) Bid Closing 11/26/2025: Target Implementation of Contract

TERMS OF SUBMISSION:

All material received in response to this bid shall become the property of the State and shall not be returned to the Vendor. Regardless of the Vendors selected, the State reserves the right to use any information presented in a bid response. The content of each Vendor’s bid shall become public information once a contract(s) has been awarded.

A responding bid that has been completed and signed by your representative shall constitute your company’s acceptance of all State of New Hampshire terms and conditions and shall legally obligate your company to these terms and conditions.

A signed response further signifies that from the time the bid is published (bid solicitation date and time) until a contract is awarded, no bidder shall offer or give, directly or indirectly, any gift, expense reimbursement, or honorarium, as defined by RSA 15-B, to any elected official, public official, public employee, constitutional official, or family member of any such official or employee who shall select, evaluate, or award the RFB.

Furthermore, a signed response signifies that any terms and/or conditions that may be or have been submitted by the Vendor are specifically null and void and are not a part of this bid invitation or any awarded purchase order, even if said terms and/or conditions contain language to the contrary.

The form P-37 Contract attached hereto shall be part of this bid and the basis for the contract(s). The successful Vendor and the State, following notification, shall promptly execute this contract form, which is to be completed by incorporating the service requirements and price conditions established by the vendor’s offer.

Complete bids shall be filled out on the original documents and format that are a part of this bid invitation.

Vendors may submit additional paperwork with pricing, but all pricing shall be on the documents provided with this bid invitation and in the State’s format.

CONTRACT TERM:

The term of the contract shall commence upon approval by the Governor and Executive Council continue thereafter through ending date April 30, 2026.

CONTRACT AWARD:

The award shall be made to the Vendor meeting the criteria established in this RFB and providing the lowest cost in total. The State reserves the right to reject any or all bids or any part thereof and add/delete items/locations to the contract. All award(s) shall be, in the form of a State of New Hampshire Contract.

https://das.nh.gov/Purchasing/vendorresources.asp

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Successful Vendor shall not be allowed to require any other type of order, nor shall the successful Vendor be allowed to require the filling out or signing of any other document by State of New Hampshire personnel.

NOTIFICATION AND AWARD OF CONTRACT(S):

Bid results shall not be given by telephone. For Vendors wishing to attend the bid closing, the names of the vendors submitting responses and pricing shall be made public. Other specific response information shall not be given out. Bid results shall be made public after final approval of the contract(s).

Bid results may also be viewed on our website at https://das.nh.gov/purchasing

For Vendors wishing to attend the bid closing: Names of the Vendors submitting responses and pricing shall be made public. In lieu of in person public bid openings the State shall conduct openings via electronic means until further notice.

LIABILITY:

The State shall not be held liable for any costs incurred by Vendors in the preparation of bids or for work performed prior to contract issuance.

PUBLIC DISCLOSURE OF BID OR PROPOSAL SUBMISSIONS:

Generally, the full contents of any bid or proposal (including all materials submitted in connection with it, such as attachments, exhibits, addenda, and vendor presentations) become public information upon completion of final contract or purchase order negotiations with the selected vendor. Certain information concerning bids or proposals, including but not limited to pricing or scoring, is generally available to the public even before this time, in accordance with the provisions of NH RSA 21-G: 37.

To the extent consistent with applicable state and federal laws and regulations, as determined by the State, including, but not limited to, NH RSA Chapter 91-A (the “Right-to-Know” Law), the State shall, after final negotiations with the selected vendor are complete, attempt to maintain the confidentiality of portions of a bid or proposal that are clearly and properly marked by a bidder as confidential. Any and all information contained in or connected to a bid or proposal that a bidder considers confidential shall be clearly designated in the following manner:

If the bidder considers any portion of a submission confidential, they shall provide a separate copy of the full and complete document, fully redacting those portions by blacking them out and shall note on the applicable page or pages of the document that the redacted portion or portions are “confidential.” Use of any other term or method, such as stating that a document or portion thereof is “proprietary”, “not for public use”, or “for client’s use only”, is not acceptable. In addition to providing an additional fully redacted copy of the bid submission to the person listed as the point of contact on Page one (1) of this document, the identified information considered to be confidential must be accompanied by a separate letter stating the rationale for each item designated as confidential. In other words, the letter must specifically state why and under what legal authority each redaction has been made.

Submissions which do not conform to these instructions by failing to include a redacted copy (if required), by failing to include a letter specifying the rationale for each redaction, by failing to designate redactions in the manner required by these instructions, or by including redactions which are contrary to these instructions or operative law may be rejected by the State as not conforming to the requirements of the bid or proposal. The State will generally assume that a bid or proposal submitted without an additional redacted copy contains no information which the bidder deems confidential. Bids and proposals which contain no redactions, as well as redacted versions of submissions that have been accepted by the State, may be released to the public, including by means of posting on State web sites.

The State shall have no obligation to maintain the confidentiality of any portion of a bid, proposal or related material, which is not marked in accordance with the foregoing provisions. It is specifically understood and agreed that the bidder waives any claim of confidentiality as to any portion of a response to this RFB or RFP that is not marked as indicated above, and that unmarked (or improperly marked) submissions may be disseminated to any person, without limitation. Marking an entire bid, proposal, attachment or full sections thereof confidential without https://das.nh.gov/purchasing

Page 4 of 10 Contractor Initials ____ taking into consideration the public’s right to know shall neither be accepted nor honored by the State.

Notwithstanding any provision of this request for submission to the contrary, proposed pricing shall be subject to public disclosure REGARDLESS of whether or not marked as confidential.

If a request is made to the State by any person or entity to view or receive copies of any portion of a proposal and if disclosure is not prohibited under NH RSA 21-G:37 or any other applicable law or regulation, bidders acknowledge and agree that the State may disclose any and all portions of the proposal or related materials which is not marked as confidential. In the case of bids, proposals or related materials that contain portions marked confidential, the State shall assess what information it believes is subject to release; notify the bidder that the request has been made; indicate what, if any, portions of the proposal or related material shall not be released; and notify the bidder of the date it plans to release the materials. The State is not obligated to comply with a bidder’s designation regarding confidentiality. The State shall have no obligation to advise a bidder that an individual or entity is attempting to electronically access, or has been referred to, materials which have been made publicly available on the state’s web sites.

By submitting a bid or proposal, the bidder agrees that unless it obtains and provides to the State, prior to the date specified in the notice described in the paragraph above, a court order valid and enforceable in the State of New Hampshire, at its sole expense, enjoining the release of the requested information, the State may release the information on the date specified in the notice without any liability to the bidder.

Notwithstanding NH RSA 91-A:4, no information shall be available to the public, or to the members of the general court or its staff concerning specific responses to this bid invitation from the time this bid is published until the closing date for responses.

TERMINATION:

The State of New Hampshire shall have the right to terminate the contract at any time with written notice to the successful Vendor a thirty (30) day written notice.

VENDOR CERTIFICATIONS:

All Vendors shall be duly registered with the NH Bureau of Purchase and Property as State of New Hampshire vendors. All Vendors that are corporations, limited liability companies, or other limited liability business entities (this excludes sole proprietors and general partnerships) shall be duly registered with the New Hampshire Secretary of State to conduct business in the State of New Hampshire.

• STATE OF NEW HAMPSHIRE VENDOR APPLICATION: To be eligible for a contract award, a Vendor must have a completed Vendor Application Package on file with the NH Bureau of Purchase and Property. See the following website for information on obtaining and filing the required forms (no fee:

https://DAS.NH.Gov/Purchasing

• NEW HAMPSHIRE SECRETARY OF STATE REGISTRATION: To be eligible for a contract award, a Vendor that is a corporation, limited liability company, or other limited liability business entity (this excludes sole proprietors and general partnerships) must be registered to conduct business in the State of New Hampshire AND in good standing with the NH Secretary of State. Please visit the following website to

Find out more about the requirements for registration with the NH Secretary of State:

http://sos.nh.gov/Corp_Div.aspx

• CONFIDENTIALITY & CRIMINAL RECORD: If Applicable, any employee or approved subcontractor of the Vendor who will be accessing or working with records of the State of New Hampshire shall be required to sign a Confidentiality and Non-Disclosure Agreement and a Release of Criminal Record Authorization Form. These forms shall be returned to the designated State agency prior to commencing any work.

• CERTIFICATE OF INSURANCE:

Prior to being awarded a contract the Vendor shall be required to submit proof of comprehensive https://das.nh.gov/Purchasing http://sos.nh.gov/Corp_Div.aspx

Page 5 of 10 Contractor Initials ____ general liability insurance coverage prior to performing any services for the State. The coverage shall insure against all claims of bodily injury, death or property damage in amounts of not less than $1,000,000 per occurrence and $2,000,000 aggregate. Coverage shall also include State of New Hampshire workers’ compensation insurance to the extent required by RSA Chapter 281-A.

BID PRICES:

Bid prices shall remain firm for the entire contract period and shall be in US dollars and shall include delivery and all other costs required by this bid invitation. Special charges, surcharges (including credit card transaction fees), or fuel charges of any kind (by whatever name) may not be added on at any time. Any and all charges shall be built into your bid price at the time of the bid. Unless otherwise specified, prices shall be F.O.B.

DESTINATION, (included in the price bid), which means delivered to a state agency's receiving dock or other designated point as specified in this contract or subsequent purchase orders without additional charge.

Shipments shall be made in order to arrive at the destination at a satisfactory time for unloading during receiving hours

Per Administrative Rule 606.01(e) “if there is a discrepancy between the unit price and the extension price in a response to an RFP, RFB or RFQ, the unit price shall be binding upon the vendor”

Price decreases shall become effective immediately as they become effective to the general trade or the Vendor’s best/preferred customer

AUDITS AND ACCOUNTING:

The successful Vendor shall allow representatives of the State of New Hampshire to have complete access to all records for the purpose of determining compliance with the terms and conditions of this bid invitation and in determining the award and for monitoring any resulting contract.

At intervals during the contract term, and prior to the termination of the contract, the successful Vendor may be required to provide a complete and accurate accounting of all products and quantities ordered by each agency and institution and by political sub-divisions and authorized non-profit organizations

ESTABLISHMENT OF ACCOUNTS:

Each State of New Hampshire agency shall have its own individual customer account number. There may also be instances where divisions or bureaus within an agency will need their own individual customer account numbers.

Should any State of New Hampshire agency place an order under the contract, the successful Vendor agrees to establish an account within three business days from the date the order is placed. However, there shall be no delay in any shipment, the agency shall receive the items ordered in accordance with the delivery time required under the “Delivery Time” section of this bid invitation, as if an account already exists for the agency.

PAYMENT:

Payment may made via ACH. Use the following link to enroll with the State Treasury for ACH payments:

https://www.nh.gov/treasury/state-vendors/index.htm

INVOICING:

Invoices shall be submitted monthly to the requesting agency. Payment shall be paid in full within thirty (30) days after receipt of invoice and acceptance to the State’s satisfaction.

VENDOR RESPONSIBILITY:

The successful Vendor shall be solely responsible for meeting all terms and conditions specified in the bid, and any resulting contract.

All State of New Hampshire bid invitations and addenda to these bid invitations are advertised on our website at: https://das.nh.gov/Purchasing/vendorresources.asp.

https://www.nh.gov/treasury/state-vendors/index.htm https://das.nh.gov/Purchasing/vendorresources.asp

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It is a prospective Vendor’s responsibility to access the website to determine any bid invitation under which they participate.

It is also the Vendor(s)’s responsibility to access the website for any posted addendum.

The website is updated several times per day; it is the responsibility of the prospective Vendor to access the website frequently to ensure that no bidding opportunity or addendum is overlooked.

It is the prospective Vendor’s responsibility to forward a signed copy of any addendum requiring the Vendor’s signature to the Bureau of Purchase and Property with the bid response.

In preparation of a bid response, the prospective Vendor shall:

• Provide pricing information as indicated in the “Offer” section; and

• Provide all other information required for the bid response (if applicable); and

• Complete the “Vendor Contact Information” section; and

• Add applicable prospective Vendor information to the “Transmittal Letter” form, and sign the form in the space provided. The Transmittal Letter form must be signed under oath and acknowledged by a notary public or justice of the peace in order for the bid response to be considered.

IF AWARDED A CONTRACT:

The successful Vendor shall complete the following sections of the attached Agreement State of New Hampshire Form #P-37:

Section 1.3 Contractor Name Section 1.4 Contractor Address Section 1.11 Contractor Signature Section 1.12 Name & Title of Contractor Signatory (if Vendor is not a sole proprietor)

• Provide certificate of insurance indicating the coverage amounts required by Section 14 of the Form Number P-37.

• Provide proof of sufficient workers’ compensation insurance coverage or evidence of exemption from RSA Chapter 81-A.

• If the successful Vendor is a corporation, limited liability company, or other limited liability business entity, then provide a certificate of good standing issued by the NH Secretary of State or, for a newly incorporated, formed, or registered entity, a copy of the appropriate registration document certified by the NH Secretary of State.

SPECIFICATIONS:

Complete specifications required are detailed in the SCOPE OF SERVICES section of this bid invitation. In responding to the bid invitation, the prospective Vendor shall address all requirements for information as outlined herein.

SITE VISITATION:

Prior to bidding, it is each Vendor's responsibility to become thoroughly familiar with the sites of the intended service, to determine everything necessary to accomplish the services. Failure of the Vendor to make a site visit does not relieve the Vendor of responsibility to fully understand what is necessary to accomplish a successful and complete annual maintenance agreement. There is a mandatory site visit on Tuesday, September 16 at 2pm at the Peabody Lodge. The Lodge is located at 260 Tramway, Dr, Franconia, NH 03580.

SCOPE OF SERVICES:

General Overview

The Owner (Cannon Mountain Ski Area, Franconia Notch State Park) is soliciting bids from qualified contractors to provide all labor, materials, and equipment necessary to remove existing carpet and supply and install new commercial carpet tile in

Page 7 of 10 Contractor Initials ____ the “Yellow Room” of Peabody Lodge. This is a high-use public area subject to heavy traffic, snow, water, and dirt, requiring a durable, low-maintenance commercial flooring solution.

Contractor Responsibilities

The selected contractor shall:

1. Site Visit & Measurements

• Perform a mandatory site visit to verify existing conditions and confirm all field measurements.

• Owner’s preliminary measurement is ~3,250 sq ft; contractor is responsible for final takeoffs.

2. Removal & Disposal

• Strip and remove existing carpet and adhesive.

• Prepare substrate by scraping, cleaning, and patching as required to ensure proper adhesion.

• Dispose of all old materials in accordance with state/local regulations.

3. Supply & Delivery

• Furnish and deliver carpet tile in quantities sufficient for coverage plus attic stock (minimum 5% extra).

• Provide all adhesives, transitions, base cove (if needed), and related installation materials.

4. Installation

• Install new carpet tile in accordance with manufacturer’s specifications and industry best practices.

• Layout to follow one of the approved methods (e.g., Quarter Turn) as directed by Owner.

• Ensure tight seams, straight alignment, and consistent appearance throughout the room.

• Protect adjacent finishes and maintain a clean worksite.

5. Cleanup & Closeout

• Remove all debris and waste materials.

• Provide Owner with maintenance instructions and manufacturer’s warranty documentation.

Carpet Specifications

The Owner has selected three approved product lines and colorways for bidding. Vendors may bid one or more of the following approved products. Substitutions are not allowed without prior written approval.

Option A – NRF Select “Foundation” (Solution Dyed Olefin Carpet Tile)

Color/Pattern: 879 014 Graphite (or Owner-approved equivalent)

Fiber Type: Solution Dyed Olefin

Size: 19.7” x 19.7” (50 cm x 50 cm)

Gauge: 1/12

Backing: PVC Free, Four Layer European Spec

Density: 5,000

Performance: ASTM E 648 Class I (Glue Down), ASTM E 662 < 450, AATCC-134 < 20 KV, IAQ Green Label Plus Certified

Warranty: Lifetime comprehensive stain (no exclusions), lifetime backing performance, lifetime commercial wear

Installation Method: Quarter Turn

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Option B – NRF Select “Contrax II” (Solution Dyed Nylon Carpet Tile)

Color/Pattern: 75173 Iron Ore (or Owner-approved equivalent)

Fiber Type: 100% Anti-Static SD BCF Colorloc™ Nylon

Size: 19.68” x 19.68” (50 cm x 50 cm)

Backing: Non-Woven Polyester

Tufted Weight: 21 oz. per sq. yd. (711 g/m²)

Density: 6,872

Performance: ASTM E 648 Class I (Glue Down), ASTM E 662 < 450, AATCC-134 < 3.0 KV, IAQ Green Label Plus Certified

Warranty: Lifetime limited warranty on commercial wear, antistatic, against delamination and backing deterioration

Installation Methods: Quarter Turn

Option C – NRF Select “Bandwidth” (Solution Dyed Nylon Carpet Tile)

Color/Pattern: 883 011 Ancient Root (or Owner-approved equivalent)

Fiber Type: Solution Dyed Nylon

Size: 19.7” x 19.7” (50 cm x 50 cm)

Gauge: 1/12

Backing: PVC Free

Tufted Weight: 18 oz. per sq. yd. (610 g/m²)

Density: 6,050

Performance: ASTM E 648 Class I (Glue Down), ASTM E 662 < 450, AATCC-134 < 20 KV, IAQ Green Label Plus Certified

Warranty: Lifetime stain resistance, lifetime backing performance, lifetime commercial wear

Installation Methods: Quarter Turn

Owner Requirements

• Contractor must provide samples for final Owner approval prior to ordering.

• Installation must be completed within agreed schedule and during a time that minimizes disruption to Lodge operations.

• Contractor to carry all necessary insurance and comply with all state requirements.

PROJECT BUDGET:

The Budget for this project is fixed and may not exceed contracted amount unless approved by Cannon Mt management. The bidder shall agree that the budget is firm and shall remain so throughout the performance of work.

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All services performed under this Contract(s) shall be performed between the hours of 7:00 A.M. and 4:00 P.M unless other arrangements are made in advance with the State. Any deviation in work hours shall be pre-approved by the Contracting Officer. The State requires ten-day advance knowledge of said work schedules to provide security and access to respective work areas. No premium charges shall be paid for any off-hour work.

The Vendor shall not commence work until a conference is held with each agency, at which representatives of the Vendor and the State are present. The conference shall be arranged by the requesting agency (State).

The State shall require correction of defective work or damages to any part of a building or its appurtenances when caused by the Vendor’s employees, equipment or supplies. The Vendor shall replace in satisfactory condition all defective work and damages rendered thereby or any other damages incurred. Upon failure of the Vendor to proceed promptly with the necessary corrections, the State may withhold any amount necessary to correct all defective work or damages from payments to the Vendor.

The work staff shall consist of qualified persons completely familiar with the products and equipment they shall use. The Contracting Officer may require the Vendor to dismiss from the work such employees as deems incompetent, careless, insubordinate, or otherwise objectionable, or whose continued employment on the work is deemed to be contrary to the public interest or inconsistent with the best interest of security and the State.

The Vendor or their personnel shall not represent themselves as employees or agents of the State.

While on State property, employees shall be subject to the control of the State, but under no circumstances shall such persons be deemed to be employees of the State.

All personnel shall observe all regulations or special restrictions in effect at the State Agency.

The Vendor’s personnel shall be allowed only in areas where services are being performed. The use of State telephones is prohibited.

If sub-contractors are to be utilized, please include information regarding the proposed sub-contractors including the name of the company, their address, contact person and three references for clients they are currently servicing. Approval by the State must be received prior to a sub-contractor starting any work.

OBLIGATIONS AND LIABILITY OF THE VENDOR:

The successful vendor shall perform all the work and furnish all the materials, tools, equipment and safety devices necessary to perform in the manner and within the time hereinafter specified. Vendor shall complete the entire work to the satisfaction of the State and in accordance with the specifications herein mentioned, at the price herein agreed upon and fixed therefore. All the work, labor and equipment to be done and furnished under this contract(s), shall be done and furnished strictly pursuant to, and in conformity with the specifications described herein, and the directions of the State representatives as given from time to time during the progress of the work, under the terms of this contract(s) and also in accordance with contract drawings.

The successful Vendor shall take full responsibility for the work to be performed pursuant to the Scope of Services included herein; for the protection of said work; and for preventing injuries to persons and damage to property and utilities on or about said work. The Vendor shall in no way be relieved of such responsibility by any authority of the State to give permission or issue orders relating to any part of the work, by any such permission given or orders issued, or by any failure of the State to give such permission or issue such orders. The successful Vendor shall bear all losses accruing to the Vendor as a result of the amount, quality, or character of the work required, or because the nature or characteristics of the work location is different from what the Vendor estimated or expected, or due to delays or other complications caused by the weather, elements, or other natural causes.

OFFER:

Vendor hereby offers to provide the services to the State of New Hampshire as specified at the prices quoted below. In complete accordance with general and detailed specifications included herewith.

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COST:

Provide all labor, materials, and equipment to remove existing carpet, prepare substrate, and supply and install new commercial carpet tile in the Peabody Lodge “Yellow Room,” including attic stock and warranties.

Description Category Cost Removal of existing carpet Labor Substrate preparation (cleaning, leveling, patching as needed) Labor Installation of new commercial carpet tile Labor Supply of commercial carpet tile Materials Attic stock (extra carpet tile for future repairs) Materials Adhesives, underlayment, and installation materials Materials Total

VENDOR CONTACT INFORMATION:

Please provide contact information below for a person knowledgeable of and who can answer questions regarding, this bid response.

Contact Person Local Telephone Number Toll Free Telephone Number

Fax Number E-mail Address Company Website

Vendor Company Name Vendor Address

I certify the accuracy of this information:

Signature of Contact Person Date