UASGS_Consultant Madatory Form.pdf

PDF 123 KB Posted

Attached to
MassDOT RFR Uncrewed Aircraft Systems Integration, & Program Support
Solicitation number
BD-24-1030-CPO1-CPO1-101747
Issued by
Suffolk County, Massachusetts

About this file

This document is a Consultant Contractor Mandatory Submission Form related to a Request for Response (RFR) for the Massachusetts Department of Transportation (MassDOT) to provide Uncrewed Aircraft Systems Integration and Program Support services. The bidder must provide their company name, the RFR name/title, and RFR number, as well as disclose any additional income from the Commonwealth of Massachusetts and identify any individuals with a financial interest in the contract. The bidder must also attach resumes or statements of qualifications for key personnel to be assigned to the contract performance. The form must be signed by an authorized signatory of the bidding company.

The related state and local contract opportunity is for the MassDOT to acquire Uncrewed Aircraft Systems Integration and Program Support services. The RFR does not provide additional details about the specific products, services, quantities, response dates, award dates, or contract term.

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CONSULTANT CONTRACTOR MANDATORY SUBMISSION FORM

COMPLETE THE FOLLOWING ONLY FOR CONSULTANT CONTRACTS

(Within HH and NN subsidiaries)

Bidder:________________________________________________________________________

RFR Name/Title: ________________________________________________________________ RFR Number: # _________________________________

Additional Income Disclosure. Pursuant to the provisions of M.G.L. c. 29, s 29A, the following amounts represent any contracts, grants or other income due from the Commonwealth of Massachusetts, including any political subdivision or public authority, during the period of a contract. Enter N/A if none. You may attach additional sheets as necessary.

Disclosure of Persons with Financial Interest. Pursuant to the provisions of M.G.L. c. 29, s 29A and c. 7A, s. 6., the following individuals have a financial interest in a contract and/or with more than one percent (1%) interest in the capital stock of the contractor. Enter N/A if none. You may attach additional sheets as necessary.

Key Personnel. Attach a resume or statement of qualifications for all key personnel specifically named in bidder's response to be assigned to the performance of a contract. Enter N/A if none.

The information submitted herein is certified by the Bidder to be accurate under the pains and penalties of perjury.

Signature of Authorized Signatory for Bidder: __________________________________________________

Title of Authorized Signatory for Bidder: _____________________________________________________

Date: __________________________________________________________

CONSULTANT CONTRACTOR MANDATORY

SUBMISSION FORM INSTRUCTIONS

The top part of this form is where the bidder enters his name on the "Bidder" line. The bidder's "RFR Name/Title" and "RFR Number" are entered on the next two lines by the bidder.

The bidder then fills in the next three sections if applicable. If none are applicable the bidder must enter N/A.

The bottom section the bidder live signs (original handwritten) on the "Signature of Authorized Signatory for Bidder" line. The bidder's title is entered on the "Title of Authorized Signatory Bidder" line. The bidder must also live date on the "Date" line of this form.

Please review this form after the bidder returns it to make sure all pertinent fields have been filled out properly.

Consultant Contractor Mandatory Submission Form

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