The Bidder is (check as applicable): A New York State Certified Minority-Owned Business Enterprise A New York State Certified Woman-Owned Business Enterprise A New York State Certified Minority and Woman-Owned Business Enterprise (Dual Certified) None of the above Provide the name, title, address, telephone number, and email address of the person authorized to receive Notices with regard to the contract entered into as a result of this procurement. See Section __ of the DOH Agreement (Attachment E), NOTICES. Name: Title: Address: City, State, ZIP Code: Telephone Number (including area code): Email Address: Taxpayer Identification Number: Bidder’s NYS Vendor Identification Number as discussed in Section 6.1.F, if enrolled: Bidder’s By my signature on this Attachment A, I certify to the statements made above in Section 2 and that I am authorized to bind the Bidder contractually. Furthermore, I certify that all information provided in connection with its proposal is true and accurate. Typed or Printed Name of Authorized Representative of the Bidder Title/Position of Authorized Representative of the Bidder Signature of Authorized Representative of the Bidder Date
The Bidder is (check as applicable): A New York State Certified Minority-Owned Business Enterprise A New York State Certified Woman-Owned Business Enterprise A New York State Certified Minority and Woman-Owned Business Enterprise (Dual Certified) None of the above Provide the name, title, address, telephone number, and email address of the person authorized to receive Notices with regard to the contract entered into as a result of this procurement. See Section __ of the DOH Agreement (Attachment E), NOTICES. Name: Title: Address: City, State, ZIP Code: Telephone Number (including area code): Email Address: Bidder’s Taxpayer Identification Number: Bidder’s NYS Vendor Identification Number as discussed in Section 6.1.F, if enrolled: By my signature on this Attachment A, I certify to the statements made above in Section 2 and that I am authorized to bind the Bidder contractually. Furthermore, I certify that all information provided in connection with its proposal is true and accurate. Typed or Printed Name of Authorized Representative of the Bidder Title/Position of Authorized Representative of the Bidder Signature of Authorized Representative of the Bidder Date
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