HomeMy WebLinkAboutschedule DRFP TITLE: Purchase of Thermal imaging Cameras RFP NO: (04)A-02
SCHEDULE "D"
CITY OF SUNRISE
RESPONDENTS QUALIFICATION STATEMENT
The undersigned certifies under oath the truth and correctness of all statements and all answers to questions
made hereinafter:
Company Name:
Address:
Street City State Zip Code
Telephone No: ( ) Fax No.( )
How many years has your organization been in business under its present name? Years
If Respondent is operating under Fictitious Name, submit evidence of compliance with Florida Fictitious Name
Statue:
Under what former names has your business operated? :
At what address was that business located?
Are You Certified? Yes No If Yes, ATTACH COPY OF CERTIFICATION
Are You Licensed? Yes No If Yes, ATTACH COPY OF LICENSE
Has your company or its senior officers ever declared bankruptcy?
Yes No If yes, explain:
Are you a sales representative , distributor ,broker or manufacturer of the
commodities/services proposed upon?
Have you ever received a contract or a purchase order from the City of Sunrise or other government entity?
Yes No
If Yes, explain (date, service/project, proposal title, etc):
Have you ever received a complaint on a contract, proposal, or proposal awarded to you by any government
entity?
Yes No If yes, explain:
Have you ever been debarred or suspended from doing business with any government entity?
Yes — No . If Yes, explain
17
Revised May 12, 2003
RFP TITLE: Purchase of Thermal ging Cameras
RFP NO: (04)A-02
SCHEDULE "D"
(continued)
REFERENCES:
Please list name of government agency or private firm(s) with whom you have done business within the
past five years:
Agency/Firm Name:
Address:
City/State/Zip Code:
Phone:
Fax:
Contact:
Agency/Firm Name:
Address:
City/State/Zip Code:
Phone:
Fax:
Contact:
Agency/Firm Name:
Address:
City/State/Zip Code:
Phone:
Fax:
Contact:
Agency/Firm Name:
Address:
City/State/Zip Code:
Phone:
Fax:
Contact:
YOUR COMPANY NAME
ADDRESS
Agency/Firm Name:
Address
City/State/Zip Code:
Phone:
Fax:
Contact:
Agency/Firm Name:
Address:
CitylState/Zip Code:
Phone:
Fax:
Contact:
Agency/Firm Name:
Address:
City/StatelZip Code:
Phone:
Fax:
Contact:
Agency/Firm Name:
Address:
City/StatelZip Code:
Phone:
Fax:
Contact:
PHONE: FAX:
18
Revised May 12, 2003