Attachment 1: Contractor Information & Certifications Page 1 of 3 1
Submitted by Attachment 1 Contractor Information & Certifications
(If this proposal is submitted by a joint venture, each business shall provide the information requested below)
Senior Services of Southeastern Virginia Attention: Monika Zajac-Lorke 2551 Eltham Ave, Ste Q Norfolk, VA 23513
Or via email to Monika Zajac-Lorke at MZLorke@ssseva.org
A. Acknowledgement Of Rfp & Addenda
Respondent has received the RFP and the Following Addenda (if any), receipt of which is hereby
acknowledged
Addendum Number: Date Received
Addendum Number: Date Received
Addendum Number: Date Received
Do you take any exception or have any objections to the terms and conditions to this RFP? Yes No
If “yes” please attach a separate page titled “Objections to the RFP” stating the specific paragraphs and why you are taking exception or objecting. Attachment 1: Contractor Information & Certifications Page 2 of 3 2
B. Contractors Information
Legal Business Name DBA (if used) Mailing Address Physical Address (if different) Federal Tax ID Fax Email Legal Structure Sole Proprietor Partnership Corp. LLC JV
Years in Business Under this
Name
Are you a Small, Women-owned, and Minority-owned Business (SWaM)? No Yes
SWaM #
1. Do you intend to subcontract any part of the Work: Yes No a. If “yes,” attach a listing of contractors and the work they will perform. 2. Number of staff in your firm qualified to perform the services in this proposal: 3. Has your firm been disqualified, removed, or otherwise declared in material breach or default of any public works contract by a public agency; or debarred from participating in bidding for any public works contracts? Yes No
C. References
1
Company
Contact
Phone
2
Company
Contact
Phone
3
Company
Contact
Phone
Attachment 1: Contractor Information & Certifications Page 3 of 3 3
D. Certifications
Equal Employment Opportunity: By submitting its proposal, the respondent certifies that it complies fully with all government regulations regarding nondiscriminatory employment practices. Non-collusive Affidavit: The party making the proposal, that such proposal is genuine and not collusive or sham: that said bidder has not colluded, conspired, connived or agreed, directly or indirectly with any bidder or person, to put in a sham bid or to retain from bidding, and has not in any manner, directly or indirectly, sought by agreement or collusion, or communication or conference, with any person to fix the bid price or affiant or any other bidder, or to fix any overhead profit or cost element of said bid price, or that any other bidder, or to secure any advantage against SSSEVA or any personal interest in the proposed contracts; and that all statements in said proposal or bid are true. Under penalties of perjury, as prescribed in 18 U.S.C 1001, the undersigned certifies that the statements set forth in its proposal are true and correct. (If a Corporation, President or CEO should sign; if a Partnership, a partner should sign’ and if LLC, managing member should sign. If some other employee signs, evidence of authority m must be submitted)
Submitted by
Signature Date
Printed Name Title