RFR 191229 Application for Response_Final~1.docx

The Commonwealth of Massachusetts Department of Public Health

BUREAU OF INFECTIOUS DISEASE AND LABORATORY SCIENCES

305 South Street, Jamaica Plain MA 02130

APPLICATION RESPONSE FORM

RFR TITLE: MA State Public Health Laboratory Specialized Laboratory Equipment, Supplies, and Services

RFR: 191229

Organization Company Name: [ ]

Company Website:

Address:

City: [ ] State: [ ] Zip: [ ]

FEIN: [ ]

Contact Person First Name: [ ] Last Name: [ ]

Title: [ ]

Telephone: ( ) -

E-Mail: [ ]

Contact Person Address (if different): [ ]

City: [ ] State: [ ] Zip: [ ]

Please check the primary commodity and/or service for which you are applying :

|_| Equipment and Instrumentation Purchasing |_| Equipment and Instrumentation Leasing |_| Equipment and Instrumentation Maintenance and Repair for equipment that falls within the scope of this RFR |_| Consumables, Reagents, and Supplies Purchasing |_| Other Product and Services: [List which other products/services you are applying for ]

PRIMARY COMMODITY AND/OR SERVICES OR RELATED SPECIALTY

Please provide an overview of the product(s) and/or services applying for:

Enter text here; text limit 1250 Characters

Please provide a link to your price catalog or insert a quote:

Enter text here; text limit 1250 Characters

APPLICATION PACKET

Assemble the following documents in this order:

|_| The Application Response Form |_| Prompt Pay Discount Form (PPD) |_| Price Catalog and/or Quote (or link inserted in the Application form) |_| Supplier Diversity Plan (SDP)

AFFIRMATION

Please initial next to the following statements to affirm: Initials

· Bidder is in business for at least one year ______

· Bidder is an authorized distributor of laboratory equipment and instrumentation ______

· Bidder performs CORI checks on employees, if required ______

· Bidder’s product and service are compliant with all applicable Federal laws and regulations, and all applicable Commonwealth of Massachusetts Laws and Regulations ______

I affirm that I will comply with the requirements of this Request for Response and with the terms of this proposal.

Signature _______________________________________________

Date:

The approved bidder will be placed on a Master Agreement list of vendors that are used on an as needed basis by the Department. There is no guarantee as to the number of engagements available to each vendor and some of the vendors listed may never actually be asked to engage with the Department.

4/5/18 image1.png