Submittal Form A ITB # 1027 .docx

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 Bid being deemed non-responsive.

PROJECT INFORMATION

BIDDER INFORMATION

Company Name:

Tax Identification Number (EIN):

DUNS Number:

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

CONTACT INFORMATION

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

Contact Name:

Title:

Email:

Address:

Telephone:

AMENDMENT ACKNOWLEDGEMENT

By checking this box, the Bidder acknowledges receipt of all amendments, and has incorporated all amendments into their Bid.

CONFLICT OF INTEREST

The Bidder SHALL select an option below:

The Bidder declares that there is no potential, perceived, or actual conflicts of interest that may arise as a result of their response to this ITB 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 ITB and/or subsequent award of Contract. The Bidder SHALL attach additional information to explain the conflicts.

CERTIFICATIONS

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

☐ Yes ☐ No

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

☐ Yes ☐ No

3) Does Bidder understand and agree that for breach or violation of the above term, the State has the right to annul the Contract without liability or, in its discretion, to deduct from the offered price the amount of any such fee, commission, percentage, brokerage fee, gifts, or contingencies.

☐ Yes ☐ No

4) Does Bidder affirm that it is not currently suspended, debarred, or otherwise excluded from federal or state procurement and non-procurement programs? Note: vendor information is available at https://sam.gov

☐ Yes ☐ No

5) Does the Bidder affirm that the Bid will be firm and binding for ninety (90) calendar days from the Bid opening date?

☐ Yes ☐ No

7) The Bidder confirms that it has the financial strength to perform the services required under this ITB.

☐ Yes ☐ No

8) The Bidder confirms that they can provide financial information (records, documents, etc.) and financial statements (Balance Sheet, Income Statement, and Cash-Flow Statement), to the State upon request.

☐ Yes ☐ No

* 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.

CONTRACT TERMS AND CONDITIONS

Important Note: Any modifications or exceptions to the Contract may be rejected by the State. Therefore, the Bidder is strongly encouraged to submit any proposed modifications or exceptions during the Q&A period (see Section 1.7).

* Failure to answer, or answering “No” may be grounds for disqualification. Complete the information below if you have responded “No” to the question above.

The Bidder shall review Exhibit 5 for additional information regarding the State’s Terms and Conditions. Non-material modifications or exceptions may be discussed with the apparent successful Bidder, at the discretion of the State. The State has sole discretion to determine if the modifications or exceptions would result in a material change or otherwise threaten the integrity of the procurement process. The State shall have the right to reject any and all such modifications and/or exceptions, or to call an end to such discussions, and to instruct the Bidder to amend its Bid and remove the modifications and/or exceptions. Failure to do so may result in the State finding the Bid non-responsive. The determination of materiality will be made at the State’s sole discretion. In the event that the Bidder has conditioned its Bid on the State’s acceptance or negotiation of its proposed modifications or exceptions, and the modifications or exceptions are deemed material, the Bidder will be given the opportunity to retract the proposed modifications or exceptions from its Bid. Failure to do so will result in the Bidder’s Bid being found non-responsive, after which it will receive no further consideration.

The Bidder shall identify all modifications or exceptions to the Contract Terms & Conditions provided in this ITB. The Bidder must use the template that is provided in Exhibit 5. Blanket requests to negotiate requirements, terms, or conditions will NOT be considered.

ATTESTATION AND SIGNATURE

This Submittal must be dated and signed by an officer or agent (“Representative”) duly authorized to execute contracts for the Bidder. I certify that I have read and understand this ITB and I am authorized to sign this Bid on behalf of the Bidder.

Printed Name of Representative

Signature

Date