Sources_Sought_Information_Request_Form.doc

Sources Sought Information Request Form

Project: Provide Physical Therapy, Athletic Training, and Strength and Conditioning Services Location: McEntire JNGB, Eastover SC 29044 NAICS Code: 621340 Interested firms please respond with this information form and the following requested

Information. Please complete all sections of the document.

1. Company Information:

Company name: _________________________________________________________

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

( ) 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

DUNS Number: ________________________________

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

( ) Large business ( ) Small business

( ) Small disadvantaged business ( ) 8(a) program participant

( ) HUB Zone business ( ) Woman-Owned business

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

The firm must be registered in SAM (www.sam.gov) with the socio-economic status identified above and the NAICS code specified in the sources sought notice. If the firm’s SAM record does not include this project’s 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

Sources Sought Information Request Form - Page 2 of 2

Provide Physical Therapy, Athletic Training, and Strength and Conditioning Services

3. Examples of similar work:

( ) 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.

Certification:

I understand those 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: _______________________

Email this form along with requested documents required in the Sources Sought to: jonathan.h.bailey.mil@mail.mil