Pt 08W--Offering Entity Acknowledgment Page.pdf

COMMUNITY-BASED MAY 2017

SOLICITATION FOR OFFERS OUTPATIENT CLINIC SFO No. VA101-15-R-0222

TRAVERSE CITY, MI

Offering Entity Acknowledgement for Solicitation No.: VA101-15-R-0222

The Offeror attests that the information provided below is accurate and shall be a basis for evaluation in Solicitation No.: VA101-15-R-0222. Failure to provide the required information may deem your proposal non-responsive.

Offeror Information

Offering Entity Name:

Address:

Offering Entity DUNS Number:

Offering Entity Tax Identification Number:

Authorized Official Name:

Authorized Official Phone Number:

Authorized Official E-mail:

Date of Submission:

Time Specified for Receipt of Offers:

Offering Entity/Prime Contractor Size Status: SDVOSB

VOSB

SB

Offering Entity Currently Certified in SAM under NAICS 531120

Offering Entity Currently Verified in VetBiz

Offering Entity POC Signature Date

Offering Entity POC Name