UASGS Consultant Madatory Form.pdf

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