DEPARTMENT OF LAW AND PUBLIC SAFETY



STATE OF NEW JERSEYJUVENILE JUSTICE COMMISSIONSIGNATURE PAGEDUNS NUMBER: FORMTEXT ?????CCR NUMBER: FORMTEXT ?????TAX ID NO: FORMTEXT ?????JJC BID #:PFTI-2021DATE SUBMITTED FORMTEXT ?????Contractor: FORMTEXT ?????Address: FORMTEXT ?????Telephone: ( FORMTEXT ???) FORMTEXT ?????Fax: ( FORMTEXT ???) FORMTEXT ????? Email Address: FORMTEXT ????? Contact Person: FORMTEXT ?????Title: FORMTEXT ?????Mailing Address: FORMTEXT ?????Telephone: ( FORMTEXT ???) FORMTEXT ?????Fax:( FORMTEXT ???) FORMTEXT ?????Email Address: FORMTEXT ????? Financial Officer, if applicable: FORMTEXT ?????Title: FORMTEXT ????? Mailing Address: FORMTEXT ?????Telephone: ( FORMTEXT ???) FORMTEXT ?????Fax:( FORMTEXT ???) FORMTEXT ?????Email Address: FORMTEXT ????? By signing below, I acknowledge that I have read and understand that if selected, I am required to obtain a Business Registration Certificate, complete the Delegated Purchasing Authority (DPA) Transaction Document Packet, and pay any required fees. See page 5 of the RFP for links and more information the DPA requirements. Name/Title: FORMTEXT ?????Signature: ................
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