SUBCONTRACTOR INFORMATION FORM PART I STATEMENT BY PROPOSING VENDOR – 1. CONTRACT NO. 2. Proposing Vendor Name: 3. Mailing Address Contract No. GSS18649A-SECC 4. SUBCONTRACTOR a. NAME 4c. Company OSD Classification: Certification Number: _____________________ b. Mailing Address: 4d. Women Business Enterprise Yes No 4e. Minority Business Enterprise Yes No 4f. Disadvantaged Business Enterprise Yes No 4g. Veteran Owned Business Enterprise Yes No 4h. Service Disabled Veteran Owned Business Enterprise Yes No 5. DESCRIPTION OF WORK BY SUBCONTRACTOR 6a. NAME OF PERSON SIGNING 7. BY (Signature) 8. DATE SIGNED 6b. TITLE OF PERSON SIGNING PART II ACKNOWLEDGEMENT BY SUBCONTRACTOR – 9a. NAME OF PERSON SIGNING 10. BY (Signature) 11. DATE SIGNED 9b. TITLE OF PERSON SIGNING * Use a separate form for each subcontractor
SUBCONTRACTOR INFORMATION FORM PART I – STATEMENT BY PROPOSING VENDOR 1. CONTRACT NO. Contract No. GSS18649A-SECC 2. Proposing Vendor Name: 3. Mailing Address 4. SUBCONTRACTOR a. NAME 4c. Company OSD Classification: Certification Number: _____________________ b. Mailing Address: 4d. Women Business Enterprise Yes No 4e. Minority Business Enterprise Yes No 4f. Disadvantaged Business Enterprise Yes No 4g. Veteran Owned Business Enterprise Yes No 4h. Service Disabled Veteran Owned Business Enterprise Yes No 5. DESCRIPTION OF WORK BY SUBCONTRACTOR 6a. NAME OF PERSON SIGNING 7. BY (Signature) 8. DATE SIGNED 6b. TITLE OF PERSON SIGNING PART II – ACKNOWLEDGEMENT BY SUBCONTRACTOR 9a. NAME OF PERSON SIGNING 10. BY (Signature) 11. DATE SIGNED 9b. TITLE OF PERSON SIGNING * Use a separate form for each subcontractor
GSS_18649A_Secc_forms.docx