Contractor Information - Government of New York
Attachment 3 – Contractor and Reseller Information Revised 5-12-15A Vendor will complete Attachment 3 –Contractor and Reseller Information for each Lot a Vendor is providing a Vendor Submission. Attachment 3 will be used for changes to Contracts resulting from this Solicitation. See Attachment C – Contract Modification Procedure for additional information regarding resulting Contract Modifications and Updates. FORMCHECKBOX Lot 1 – Software FORMCHECKBOX Lot 2 – Hardware FORMCHECKBOX Lot 3 – Cloud FORMCHECKBOX Lot 4 – Implementation ServicesContractor InformationContact InformationCompany Name: FORMTEXT ?????Doing Business As: FORMTEXT ?????Address: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Website: FORMTEXT ?????Federal ID #: FORMTEXT ?????NYS Vendor ID #: FORMTEXT ?????Toll-Free Number: FORMTEXT ?????Contract Administrator InformationContract Administrator Name: FORMTEXT ?????Title: FORMTEXT ?????Address: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Telephone #: FORMTEXT ?????E-Mail: FORMTEXT ?????Account Manager InformationAccount Manager Name: FORMTEXT ?????Title: FORMTEXT ?????Address: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Telephone #: FORMTEXT ?????E-Mail: FORMTEXT ?????Sales/Billing InformationContact Name: FORMTEXT ?????Title: FORMTEXT ?????Address: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Telephone #: FORMTEXT ?????Toll Free Telephone #: FORMTEXT ?????E-Mail: FORMTEXT ?????Emergency Contact InformationTelephone #: FORMTEXT ?????Toll Free Telephone #: FORMTEXT ?????E-Mail: FORMTEXT ?????Reseller InformationFor each Reseller proposed, Contractor will provide Reseller Information, including a Reseller’s M/WBE and SB status. Additional information regarding obligations placed on a Vendor and resulting Contractor in naming a Reseller are available in the Solicitation “Reseller Participation.”Minority (MBE) or Women (WBE) Owned Business Enterprise shall mean a business enterprise, including a sole proprietorship, partnership or corporation that is:at least 51% (fifty-one percent) owned and controlled by the minority members and/or women; an enterprise in which such minority and/or women ownership interest is real, substantial and continuing; an enterprise in which such minority and/or women ownership has and exercises the authority to independently control the day-to-day business decisions; and an enterprise independently owned, operated and authorized to do business in New York State.Vendors certified and listed in the Empire State Development’s Directory of Certified Minority and Women-Owned Business Enterprises () will be identified by OGS as MBEs and/or WBEs in the OGS Contract upon award of the contract. For further information and or application please contact New York State Department of Economic Development, Division of Minority and Women-Owned Business Enterprise at 518-292-5250 (Albany) or 212-803-2414 (New York City).Small Business (SB), as defined in Article 11 of New York State Finance Law, means a business which meets the following criteria:Vendor is resident in New York State;Vendor is independently owned and operated;Vendor is not dominant in its field; andVendor employs one hundred (100) or fewer persons. Reseller InformationCompany Name: FORMTEXT ?????Address: FORMTEXT ????? FORMTEXT ?????Website: FORMTEXT ?????Federal ID #: FORMTEXT ?????NYS Vendor ID #: FORMTEXT ?????Contact Name: FORMTEXT ?????Title FORMTEXT ?????Telephone #: FORMTEXT ?????E-Mail: FORMTEXT ?????M/WBE Certification:(See 2.1 above for definition) FORMCHECKBOX MBE FORMCHECKBOX WBE FORMCHECKBOX BothSBE:(See 2.2 above for definition) FORMCHECKBOX Yes FORMCHECKBOX NoQualifying Criteria FORMTEXT ?????Reseller InformationCompany Name: FORMTEXT ?????Address: FORMTEXT ????? FORMTEXT ?????Website: FORMTEXT ?????Federal ID #: FORMTEXT ?????NYS Vendor ID #: FORMTEXT ?????Contact Name: FORMTEXT ?????Title FORMTEXT ?????Telephone #: FORMTEXT ?????E-Mail: FORMTEXT ?????M/WBE Certification:(See 2.1 above for definition) FORMCHECKBOX MBE FORMCHECKBOX WBE FORMCHECKBOX BothSBE:(See 2.2 above for definition) FORMCHECKBOX Yes FORMCHECKBOX NoQualifying Criteria FORMTEXT ?????Reseller InformationCompany Name: FORMTEXT ?????Address: FORMTEXT ????? FORMTEXT ?????Website: FORMTEXT ?????Federal ID #: FORMTEXT ?????NYS Vendor ID #: FORMTEXT ?????Contact Name: FORMTEXT ?????Title FORMTEXT ?????Telephone #: FORMTEXT ?????E-Mail: FORMTEXT ?????M/WBE Certification:(See 2.1 above for definition) FORMCHECKBOX MBE FORMCHECKBOX WBE FORMCHECKBOX BothSBE:(See 2.2 above for definition) FORMCHECKBOX Yes FORMCHECKBOX NoQualifying Criteria FORMTEXT ?????Reseller InformationCompany Name: FORMTEXT ?????Address: FORMTEXT ????? FORMTEXT ?????Website: FORMTEXT ?????Federal ID #: FORMTEXT ?????NYS Vendor ID #: FORMTEXT ?????Contact Name: FORMTEXT ?????Title FORMTEXT ?????Telephone #: FORMTEXT ?????E-Mail: FORMTEXT ?????M/WBE Certification:(See 2.1 above for definition) FORMCHECKBOX MBE FORMCHECKBOX WBE FORMCHECKBOX BothSBE:(See 2.2 above for definition) FORMCHECKBOX Yes FORMCHECKBOX NoQualifying Criteria FORMTEXT ?????Reseller InformationCompany Name: FORMTEXT ?????Address: FORMTEXT ????? FORMTEXT ?????Website: FORMTEXT ?????Federal ID #: FORMTEXT ?????NYS Vendor ID #: FORMTEXT ?????Contact Name: FORMTEXT ?????Title FORMTEXT ?????Telephone #: FORMTEXT ?????E-Mail: FORMTEXT ?????M/WBE Certification:(See 2.1 above for definition) FORMCHECKBOX MBE FORMCHECKBOX WBE FORMCHECKBOX BothSBE:(See 2.2 above for definition) FORMCHECKBOX Yes FORMCHECKBOX NoQualifying Criteria FORMTEXT ?????Reseller InformationCompany Name: FORMTEXT ?????Address: FORMTEXT ????? FORMTEXT ?????Website: FORMTEXT ?????Federal ID #: FORMTEXT ?????NYS Vendor ID #: FORMTEXT ?????Contact Name: FORMTEXT ?????Title FORMTEXT ?????Telephone #: FORMTEXT ?????E-Mail: FORMTEXT ?????M/WBE Certification:(See 2.1 above for definition) FORMCHECKBOX MBE FORMCHECKBOX WBE FORMCHECKBOX BothSBE:(See 2.2 above for definition) FORMCHECKBOX Yes FORMCHECKBOX NoQualifying Criteria FORMTEXT ?????Reseller InformationCompany Name: FORMTEXT ?????Address: FORMTEXT ????? FORMTEXT ?????Website: FORMTEXT ?????Federal ID #: FORMTEXT ?????NYS Vendor ID #: FORMTEXT ?????Contact Name: FORMTEXT ?????Title FORMTEXT ?????Telephone #: FORMTEXT ?????E-Mail: FORMTEXT ?????M/WBE Certification:(See 2.1 above for definition) FORMCHECKBOX MBE FORMCHECKBOX WBE FORMCHECKBOX BothSBE:(See 2.2 above for definition) FORMCHECKBOX Yes FORMCHECKBOX NoQualifying Criteria FORMTEXT ?????Reseller InformationCompany Name: FORMTEXT ?????Address: FORMTEXT ????? FORMTEXT ?????Website: FORMTEXT ?????Federal ID #: FORMTEXT ?????NYS Vendor ID #: FORMTEXT ?????Contact Name: FORMTEXT ?????Title FORMTEXT ?????Telephone #: FORMTEXT ?????E-Mail: FORMTEXT ?????M/WBE Certification:(See 2.1 above for definition) FORMCHECKBOX MBE FORMCHECKBOX WBE FORMCHECKBOX BothSBE:(See 2.2 above for definition) FORMCHECKBOX Yes FORMCHECKBOX NoQualifying Criteria FORMTEXT ?????Reseller InformationCompany Name: FORMTEXT ?????Address: FORMTEXT ????? FORMTEXT ?????Website: FORMTEXT ?????Federal ID #: FORMTEXT ?????NYS Vendor ID #: FORMTEXT ?????Contact Name: FORMTEXT ?????Title FORMTEXT ?????Telephone #: FORMTEXT ?????E-Mail: FORMTEXT ?????M/WBE Certification:(See 2.1 above for definition) FORMCHECKBOX MBE FORMCHECKBOX WBE FORMCHECKBOX BothSBE:(See 2.2 above for definition) FORMCHECKBOX Yes FORMCHECKBOX NoQualifying Criteria FORMTEXT ?????Reseller InformationCompany Name: FORMTEXT ?????Address: FORMTEXT ????? FORMTEXT ?????Website: FORMTEXT ?????Federal ID #: FORMTEXT ?????NYS Vendor ID #: FORMTEXT ?????Contact Name: FORMTEXT ?????Title FORMTEXT ?????Telephone #: FORMTEXT ?????E-Mail: FORMTEXT ?????M/WBE Certification:(See 2.1 above for definition) FORMCHECKBOX MBE FORMCHECKBOX WBE FORMCHECKBOX BothSBE:(See 2.2 above for definition) FORMCHECKBOX Yes FORMCHECKBOX NoQualifying Criteria FORMTEXT ?????Reseller InformationCompany Name: FORMTEXT ?????Address: FORMTEXT ????? FORMTEXT ?????Website: FORMTEXT ?????Federal ID #: FORMTEXT ?????NYS Vendor ID #: FORMTEXT ?????Contact Name: FORMTEXT ?????Title FORMTEXT ?????Telephone #: FORMTEXT ?????E-Mail: FORMTEXT ?????M/WBE Certification:(See 2.1 above for definition) FORMCHECKBOX MBE FORMCHECKBOX WBE FORMCHECKBOX BothSBE:(See 2.2 above for definition) FORMCHECKBOX Yes FORMCHECKBOX NoQualifying Criteria FORMTEXT ?????Reseller InformationCompany Name: FORMTEXT ?????Address: FORMTEXT ????? FORMTEXT ?????Website: FORMTEXT ?????Federal ID #: FORMTEXT ?????NYS Vendor ID #: FORMTEXT ?????Contact Name: FORMTEXT ?????Title FORMTEXT ?????Telephone #: FORMTEXT ?????E-Mail: FORMTEXT ?????M/WBE Certification:(See 2.1 above for definition) FORMCHECKBOX MBE FORMCHECKBOX WBE FORMCHECKBOX BothSBE:(See 2.2 above for definition) FORMCHECKBOX Yes FORMCHECKBOX NoQualifying Criteria FORMTEXT ?????Reseller InformationCompany Name: FORMTEXT ?????Address: FORMTEXT ????? FORMTEXT ?????Website: FORMTEXT ?????Federal ID #: FORMTEXT ?????NYS Vendor ID #: FORMTEXT ?????Contact Name: FORMTEXT ?????Title FORMTEXT ?????Telephone #: FORMTEXT ?????E-Mail: FORMTEXT ?????M/WBE Certification:(See 2.1 above for definition) FORMCHECKBOX MBE FORMCHECKBOX WBE FORMCHECKBOX BothSBE:(See 2.2 above for definition) FORMCHECKBOX Yes FORMCHECKBOX NoQualifying Criteria FORMTEXT ?????Reseller InformationCompany Name: FORMTEXT ?????Address: FORMTEXT ????? FORMTEXT ?????Website: FORMTEXT ?????Federal ID #: FORMTEXT ?????NYS Vendor ID #: FORMTEXT ?????Contact Name: FORMTEXT ?????Title FORMTEXT ?????Telephone #: FORMTEXT ?????E-Mail: FORMTEXT ?????M/WBE Certification:(See 2.1 above for definition) FORMCHECKBOX MBE FORMCHECKBOX WBE FORMCHECKBOX BothSBE:(See 2.2 above for definition) FORMCHECKBOX Yes FORMCHECKBOX NoQualifying Criteria FORMTEXT ?????Reseller InformationCompany Name: FORMTEXT ?????Address: FORMTEXT ????? FORMTEXT ?????Website: FORMTEXT ?????Federal ID #: FORMTEXT ?????NYS Vendor ID #: FORMTEXT ?????Contact Name: FORMTEXT ?????Title FORMTEXT ?????Telephone #: FORMTEXT ?????E-Mail: FORMTEXT ?????M/WBE Certification:(See 2.1 above for definition) FORMCHECKBOX MBE FORMCHECKBOX WBE FORMCHECKBOX BothSBE:(See 2.2 above for definition) FORMCHECKBOX Yes FORMCHECKBOX NoQualifying Criteria FORMTEXT ?????Reseller InformationCompany Name: FORMTEXT ?????Address: FORMTEXT ????? FORMTEXT ?????Website: FORMTEXT ?????Federal ID #: FORMTEXT ?????NYS Vendor ID #: FORMTEXT ?????Contact Name: FORMTEXT ?????Title FORMTEXT ?????Telephone #: FORMTEXT ?????E-Mail: FORMTEXT ?????M/WBE Certification:(See 2.1 above for definition) FORMCHECKBOX MBE FORMCHECKBOX WBE FORMCHECKBOX BothSBE:(See 2.2 above for definition) FORMCHECKBOX Yes FORMCHECKBOX NoQualifying Criteria FORMTEXT ?????Sales Agent InformationFor each Sales Agent proposed, Contractor will provide Agent Information, including a Sales Agent’s M/WBE and SB status. Sales Agent InformationAgent Name: FORMTEXT ?????Address: FORMTEXT ????? FORMTEXT ?????Contact Name: FORMTEXT ?????Title FORMTEXT ?????Telephone #: FORMTEXT ?????E-Mail: FORMTEXT ?????M/WBE Certification:(See Section 2.1 for definition) FORMCHECKBOX MBE FORMCHECKBOX WBE FORMCHECKBOX BothSBE:(See Section 2.2 for definition) FORMCHECKBOX Yes FORMCHECKBOX NoSales Agent InformationAgent Name: FORMTEXT ?????Address: FORMTEXT ????? FORMTEXT ?????Contact Name: FORMTEXT ?????Title FORMTEXT ?????Telephone #: FORMTEXT ?????E-Mail: FORMTEXT ?????M/WBE Certification:(See Section 2.1 for definition) FORMCHECKBOX MBE FORMCHECKBOX WBE FORMCHECKBOX BothSBE:(See Section 2.2 for definition) FORMCHECKBOX Yes FORMCHECKBOX NoSales Agent InformationAgent Name: FORMTEXT ?????Address: FORMTEXT ????? FORMTEXT ?????Contact Name: FORMTEXT ?????Title FORMTEXT ?????Telephone #: FORMTEXT ?????E-Mail: FORMTEXT ?????M/WBE Certification:(See Section 2.1 for definition) FORMCHECKBOX MBE FORMCHECKBOX WBE FORMCHECKBOX BothSBE:(See Section 2.2 for definition) FORMCHECKBOX Yes FORMCHECKBOX NoSales Agent InformationAgent Name: FORMTEXT ?????Address: FORMTEXT ????? FORMTEXT ?????Contact Name: FORMTEXT ?????Title FORMTEXT ?????Telephone #: FORMTEXT ?????E-Mail: FORMTEXT ?????M/WBE Certification:(See Section 2.1 for definition) FORMCHECKBOX MBE FORMCHECKBOX WBE FORMCHECKBOX BothSBE:(See Section 2.2 for definition) FORMCHECKBOX Yes FORMCHECKBOX No ................
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