SUBMITTAL FORM A

Background, Declarations, & Certifications

All information requested in this Submittal Form is Mandatory.

Failure to complete or respond to each question, failure to sign this Form, and failure to submit this Form may result in your Quote not being considered for award.

PROJECT INFORMATION

RFQ Number: 1302 Project Name: IDPTV Labeling & Mailing Services

BIDDER INFORMATION

Company Name:

Company Address:

Tax Identification Number (EIN):

DUNS / UEI Number:

Legal Status: ☐ Corporation

☐ Limited Liability Corporation (LLC) ☐ Limited Liability Partnership ☐ Sole Proprietorship ☐ Other (specify)

CONTACT INFORMATION

Individual responsible for preparing this Quote, and who can be contacted for clarification on this Quote

Contact Name:

Title:

Email:

Telephone:

AMENDMENT ACKNOWLEDGEMENT

☐ By checking this box, the Bidder acknowledges receipt of all amendments issued for this solicitation, and has incorporated all amendments into their Quote.

CONFLICT OF INTEREST

The Bidder must select an option below:

☐ The Bidder declares that there is no potential, perceived, or actual conflict of interest that may arise as a result of their response to this RFQ and/or subsequent award of Contract.

☐ The Bidder declares that there are potential, perceived, or actual conflicts of interest that may arise as a result of their response to this RFQ and/or subsequent award of Contract.

The Bidder must attach additional information to explain the conflicts.

CERTIFICATIONS

QUESTION RESPONSE*

1) Is Bidder a legal entity with the legal right to contract?

☐ Yes ☐ No

2) Is Bidder in compliance with applicable equal employment regulations?

3) Does Bidder affirm that it is not currently suspended, debarred, or otherwise excluded from federal or state procurement and non-procurement programs? (Vendor information available at sam.gov)

4) Does Bidder warrant that it does not knowingly and willfully employ persons who cannot legally work in this country; and that Bidder takes steps to verify that it does not hire persons who have entered our nation illegally or cannot legally work in the United States; and that any misrepresentation in this regard or any employment of such persons constitutes a material breach and will be cause for the imposition of monetary penalties up to five percent (5%) of the Contract price, per violation, and/or termination of the Contract?

5) Does the Bidder affirm and acknowledge that the State manages all vendor profiles and payment preferences exclusively through PaymentWorks, and that organizations selected for award must register or update their PaymentWorks account to avoid delays in contract awards and payments?

* Failure to answer, or answering “No” may be grounds for disqualification. Attach additional information on any subject where the Bidder responded “No” to a question above.

ATTESTATION AND SIGNATURE

This Submittal must be dated and signed by an officer or agent (“Representative”) duly authorized to execute contracts for the Bidder. By my signature I accept the terms, conditions and requirements contained in the solicitation, including, but not limited to, the State of Idaho Standard Contract Terms and Conditions, and the solicitation instructions in effect at the time this RFQ was issued, as incorporated by reference into this solicitation; as well as any special terms and conditions incorporated in the solicitation documents. As the undersigned, I certify I am authorized to sign and submit this response for the named Bidder. I further acknowledge I am responsible for reviewing and acknowledging any addendums that have been issued for this solicitation.

Printed Name of Representative Signature Date