Vendor Information Response~1.docx
DOCX document 38 KB Posted
- Solicitation number
- 99SWC-S1735
- Issued by
- Churchill County, Nevada
About this file
This document is a Vendor Information Response form for a state and local contract opportunity in Nevada. The vendor must complete and return this form as part of their proposal submission. The form collects detailed information about the vendor, including company profile, licensing, experience with the State of Nevada, any conflicts of interest, and prior or ongoing contractual issues. The contract opportunity is for Monoclonal Antibody Treatment Mobile Outpatient Services in the state of Nevada. Vendors must provide their company name, ownership structure, incorporation details, years in business, key personnel, office locations, and the number of employees capable of supporting the requirements. Vendors must also disclose any Nevada business licenses, prior work for the State of Nevada, and any current or former state employees involved. Finally, vendors must indicate if they will accept payment via procurement card.
The second paragraph outlines additional details related to the pricing and payment terms, as well as any set-asides, incumbents, funding sources, and other salient information. However, these details are not explicitly provided in the document reviewed.
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Text version
VENDOR INFORMATION RESPONSE
VENDOR INFORMATION RESPONSE
Vendors shall complete and return this form in their proposal.
If the proposal includes subcontractors, form must be completed for each subcontractor as well.
VENDOR CONTACT INFORMATION
COMPANY NAME AND CONTACT INFORMATION:
The information provided in the table below shall be used for development of the contract, if awarded.
| Requested Information |
| Response |
Company Name:
Company Street Address:
City, State, Zip Code:
Telephone Number, including area code:
Toll Free Number, including area code:
Email Address:
CONTACT PERSON FOR QUESTIONS/CONTRACT NEGOTIATIONS
| Requested Information |
| Response |
Name:
Title:
Address:
City, State, Zip Code:
Email Address:
Telephone Number, including area code:
Toll Free Number, including area code:
VENDOR INFORMATION
Vendors shall provide an overall company profile in the following table:
| Question |
| Response |
Company Name:
Ownership (sole proprietor, partnership, etc.):
State of Incorporation:
Date of Incorporation:
# of years in business:
List of top officers:
Location of company headquarters, to include City and State:
Location(s) of the office that shall provide the services described in this RFP:
Number of employees locally with the expertise to support the requirements identified in this RFP:
Number of employees nationally with the expertise to support the requirements in this RFP:
Location(s) from which employees shall be assigned for this project:
VENDOR LICENSING
Please be advised: Pursuant to NRS 80.010, a corporation organized pursuant to the laws of another state shall register with the State of Nevada, Secretary of State’s Office as a foreign corporation before a contract can be executed between the State of Nevada and the awarded vendor, unless specifically exempted by NRS 80.015.
The selected vendor, prior to doing business in the State of Nevada, shall be appropriately licensed by the State of Nevada, Secretary of State’s Office pursuant to NRS 76. Information regarding the Nevada Business License can be located at http://nvsos.gov.
| Question |
| Response |
Nevada Business License Number:
Legal Entity Name:
| Is the Legal Entity Name the same name as vendor is Doing Business As (DBA)? |
| Yes |
No
If the answer is ‘No’, provide explanation below:
STATE OF NEVADA EXPERIENCE
| Question |
| Response |
| Has the vendor ever been engaged under contract by any State of Nevada agency? |
| Yes |
No
If ‘Yes’, complete the following table for each State agency for whom the work was performed.
Table can be duplicated for each contract being identified.
| Question |
| Response |
State Agency Name:
State Agency Contact Name:
Dates Services Were Performed:
Type of Duties Performed:
Total Dollar Value of the Contract:
CURRENT OR FORMER EMPLOYEE
| Question |
| Response |
| Are you now or have you been within the last two (2) years an employee of the State of Nevada, or any of its agencies, departments, or divisions? |
| Yes |
No
If ‘Yes’, please explain when the employee is planning to render services; i.e., while on annual leave, compensatory time, or on their own time?
If you employ (a) any person who is a current employee of an agency of the State of Nevada, or (b) any person who has been an employee of an agency of the State of Nevada within the past two (2) years, and if such person shall be performing or producing the services which you shall be contracted to provide under this contract, you shall disclose the identity of each such person in your response to this RFP, and specify the services that each person shall be expected to perform.
PRIOR OR ONGOING CONTRACTUAL ISSUES
Disclosure of any significant prior or ongoing contract failures, contract breaches, civil or criminal litigation in which the vendor has been alleged to be liable or held liable in a matter involving a contract with the State of Nevada or any other governmental entity.
Any pending claim or litigation occurring within the past six (6) years which may adversely affect the vendor’s ability to perform or fulfill its obligations if a contract is awarded as a result of this RFP shall also be disclosed.
| Question |
| Response |
| Does any of the above apply to your company? |
| Yes |
No
If ‘Yes’, please provide the information in the table below.
Table can be duplicated for each issue being identified.
| Question |
| Response |
Date of alleged contract failure or breach:
Parties involved:
Description of the contract failure, contract breach, or litigation, including the products or services involved:
Amount in controversy:
Resolution or current status of the dispute:
| If the matter has resulted in a court case: |
| Court |
| Case Number |
Status of the litigation:
PAYMENT AUTHORIZATION FOR USE OF PROCUREMENT CARD
Using agencies may desire to use a Procurement Card as a method of payment to vendors.
PAYMENT AUTHORIZATION FOR USE OF PROCUREMENT CARD
| Question |
| Response |
| Please indicate if you will accept this method of payment? |
| Yes |
No
NAME OF INDIVIDUAL AUTHORIZED TO BIND THE ORGANIZATION
| Requested Information |
| Response |
Name:
Title:
SIGNATURE OF INDIVIDUAL AUTHORIZED TO BIND THE VENDOR
Individual shall be legally authorized to bind the vendor per NRS 333.337
Signature:
Date:
Revised: April 2021 Page 2 of 2
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