Company_Information_Attachment.doc

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Technician Occupational Medical Surveillance ExaminationServices
Solicitation number
W912KC-16-R-1002
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Company Information:

If your organization has the potential capacity to perform these contract services, please provide the following information:

1. Company Information:

Company Name: DUNS Number:

Company Address as registered in System for Award Management (SAM) (formally CCR):

( ) I have confirmed that my address listed above is exactly the same as listed in (SAM)

( ) The above address is not the same in (SAM), but registration is being corrected to the above listed address

Socio –economic status for the NAICS code- please check all that apply:

( ) Large Business ( ) Small Business

( ) Small Disadvantaged Business ( ) 8(a) Program Participant

( ) HUB Zone Business ( ) Women Owned Business

( ) Service-Disabled Veteran-Owned Small Business (SDVOSB)

The firm must be registered in SAM https://www.sam.gov/portal/public/SAM/ with the socio-economic status identified above and the NAICS code specified in the sources sought notice. If the firms SAM record does not include this projects NAICS code, the firm will not be considered.

( ) I have confirmed that my firm is registered in SAM for the NAICS code and business type selected ( ) My firm is not registered in SAM with the NAICS code and business status selected, but the firm qualifies and registration is in process ( ) My firm is not registered in SAM for the identified NAICS code

2. Examples of Similar Work Performed in Pennsylvania:

( ) I have attached three references for similar work that our firm has performed.

( ) I have not attached three references of similar work that our firm has performed.

3. Provide Credentials to perform as a Medical Business entity in Pennsylvania:

( ) I have attached the credentials to perform as a Medical Business entity in Pennsylvania.

( ) I have not attached credentials to perform as a Medical Business entity in Pennsylvania.

I understand that incomplete answers in sections or my failure to provide required documentation or failure to sign this certification may remove my firm from consideration for this project sources sought notice.

Signature:

Name:

Title:

Phone Number:

File details come from the government source that posted it. Updated .