IFB Template .gov
Exhibit?A-2 – Bidder’s ProfileCompetitive Solicitation No.:02619Bidder:Bidder InformationLegal name (from Business License) and address:___________________________Business Name___________________________Address___________________________City, State, Zip CodeWashington State Department of Revenue Registration NumberNote: This is the Unified Business Identifier (UBI)___________________Federal Tax ID No. (TIN):Note: If your TIN is a Social Security number, provide only the last four digits.___________________Is your firm certified as a minority or woman owned business with the Washington State Office of Minority & Women’s Business Enterprises (OMWBE)?Yes FORMCHECKBOX No FORMCHECKBOX If yes, provide MWBE certification no. ________Is your firm a self-certified Washington State small business?Note: See definitions of ‘microbusiness,’ ‘minibusiness,’ and ‘small business,” set forth in RCW?39.26.010.Yes FORMCHECKBOX No FORMCHECKBOX If yes, what is your business size? Small FORMCHECKBOX Mini FORMCHECKBOX Micro FORMCHECKBOX Is your firm certified as Veteran Owned with the Washington State Department of Veteran Affairs?Yes FORMCHECKBOX No FORMCHECKBOX If yes, provide WSDVA certification no. __________.Contract Management Points of ContactAuthorized RepresentativeName: FORMTEXT ?????Email: FORMTEXT ?????Phone: FORMTEXT ?????Contract AdministratorName: FORMTEXT ?????Email: FORMTEXT ?????Phone: FORMTEXT ?????Sales Reporting RepresentativeName: FORMTEXT ?????Email: FORMTEXT ?????Phone: FORMTEXT ?????Sales Reporting AlternateName: FORMTEXT ?????Email : FORMTEXT ?????Phone: FORMTEXT ?????Management Fee RepresentativeName: FORMTEXT ?????Email: FORMTEXT ?????Phone: FORMTEXT ?????Management Fee Contact AlternateName: FORMTEXT ?????Email: FORMTEXT ?????Phone: FORMTEXT ?????Address for Enterprise Services to send management fee invoices:Company name: FORMTEXT ?????Attn: FORMTEXT ?????Address: FORMTEXT ?????City/State/Zip: FORMTEXT ?????Ordering/Sales Points of Contact (expand as necessary)NamePhone NumberE-mailArea of ResponsibilityReferencesProvide a minimum of three (3) commercial or government references for which bidder has delivered goods and/or services similar in scope as described in the Competitive Solicitation.Reference 1Company Name:Contact:Phone:Email: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Reference 2Company Name:Contact:Phone:Email: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Reference 3Company Name:Contact:Phone:Email: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Will Call/Service LocationsIdentify will call or service locations throughout the state.LocationPoint of ContactPhone NumberArea(s) of ResponsibilityPurchase Cards (i.e., credit cards)Please indicate which types of purchasing (credit) cards are accepted (note: any card fees must be included in the unit price of the bid): FORMCHECKBOX Visa FORMCHECKBOX Master Card FORMCHECKBOX American Express FORMCHECKBOX Discover FORMCHECKBOX Other: FORMTEXT ?????Return this Bidder’s Profile to Procurement Coordinator at:DESGandSTeamC@des. ................
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