TEXAS DEPARTMENT OF TRANSPORTATION
PROCUREMENT DIVISION
SPECIFICATION NO
*
TxDOT 936-34-42
REVISED: MAY 2015
PORTABLE FIRE EXTINGUISHER SERVICES – ANNUAL INSPECTION,
MAINTENANCE, REPAIR AND RECHARGING
PUBLICATION
This specification is a product of the Texas Department of Transportation (TxDOT). It is the practice of TxDOT
to support other entities by making this specification available through the National Institute of Governmental
Purchasing (NIGP). This specification may not be sold for profit or monetary gain. If this specification is altered
in any way, the header, and any and all references to TxDOT must be removed. TxDOT does not assume nor
accept any liability when this specification is used in the procurement process by any other entity.
1.
SCOPE: This solicitation is for services to provide preventive and remedial maintenance, inspection, and
repair of portable fire extinguisher. The service shall include annual inspection and as-needed
maintenance, repair and recharging of types ABC, BC, Halon, and CO2 portable fire extinguishers owned
by TxDOT.
2.
DEFINITIONS OF TERMS AND ACRONYMS
3.
2.1.
ANSI – American National Standards Institute
2.2.
NFPA – The National Fire Protection Association
2.3.
PM – Project Manager
2.4.
ST – Service Technician
2.5.
TxDOT – Texas Department of Transportation
2.6.
UL – Underwriters Laboratory
APPLICABLE LAWS AND STANDARDS: The vendor shall provide the specified service requirements in
accordance with all applicable federal, state and local laws, standards and regulations necessary to
perform the services, including, but not limited to:
3.1.
NFPA 1 – Standard for Portable Fire Extinguishers, latest edition
3.2.
ANSI/UL 711 – Rating and Fire Testing of Fire Extinguishers
3.3.
UL 299 – Dry Chemical Fire Extinguishers
3.4.
UL 154 – Carbon-Dioxide Fire Extinguishers
3.5.
UL 1093 – Standard for Halogenated Agent Fire Extinguishers
* This Specification Supersedes Specification No. TxDOT 936-34-42, Revised April 2015.
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SPECIFICATION NO
*
TxDOT 936-34-42
REVISED: MAY 2015
4.
RESPONDENT QUALIFICATIONS: The respondent shall:
4.1.
Be a company engaged in the business of providing inspection, maintenance, repair, and
recharging of portable fire extinguishers for a minimum of three years within the last six years.
Recent start-up businesses do not meet the requirements of this solicitation.
NOTE: A start-up business is defined as a new company that has no previous operational history
or expertise in the relevant business and is not affiliated with a company that has that history or
expertise. Two companies are affiliated if the two companies have a common parent company or
if one is the parent or subsidiary of the other.
4.2.
Have a current certificate of registration with the Texas State Fire Marshall.
4.3.
Be in good financial standing and current in payment of all taxes and fees such as state franchise
fees. TxDOT reserves the right to request a copy of the respondent’s audited or un-audited
financial statement.
TxDOT may request a statement from the president, owner or financial officer on company
letterhead certifying that the company is in good financial standing and current in payment of all
taxes and fees.
When financial statements are requested, TxDOT will review the respondent's audited or unaudited financial statement to this solicitation in accordance with Texas Government Code, Title
10, Subtitle D, Section 2156.007 to evaluate the sufficiency of the respondent's financial resources
and ability to perform the contract or provide the service required in the solicitation. TxDOT will
be the sole judge in determining the sufficiency of the respondent's financial resources and ability
to perform the contract or provide the service. Factors to be reviewed include:
4.3.1
Balance sheets.
4.3.2
Net working capital.
4.3.3
Current asset ratio.
4.3.4
Liquidity ratio.
4.3.5
Auditor(s) notes.
4.3.6
Any notes to the financial statements.
5.
RESPONDENT REFERENCES: The respondent should submit a minimum of three references to
substantiate the qualifications and experience requirements for similar services completed for two years
within the last five years. References shall illustrate respondent’s ability to provide the services outlined in
the specification. References shall include name, point of contact, telephone number, and dates services
were performed. The response may be disqualified if TxDOT is unable to verify qualification and
experience requirements from the respondent’s references. The response may be disqualified if TxDOT
receives negative responses. TxDOT will be the sole judge of references (Ref. – Respondent
References).
6.
KEY PERSONNEL QUALIFICATIONS: The respondent shall provide the following key personnel:
Service Technician (ST). The ST shall:
6.1.
Possess a valid Driver License acceptable in the state of Texas.
6.2.
Have no DUI or DWI incidents on driving record within the past three years.
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SPECIFICATION NO
*
TxDOT 936-34-42
REVISED: MAY 2015
7.
8.
6.3.
Have no more than two moving violations on driving record within the past three years.
6.4.
Be certified by the Texas State Fire Marshall required for the services requested.
VENDOR REQUIREMENTS: The vendor shall:
7.1.
Adhere to the TxDOT Terms and Conditions identified on the solicitation.
7.2.
Provide a primary point of contact.
7.3.
Provide a local telephone number for immediate contact with the PM and supervisor. Regional or
national telephone numbers are not acceptable. The PM or Supervisor shall return calls within two
hours of being contacted by the designated TxDOT representative. This telephone shall be
continuously monitored, 24 hours a day, seven days a week.
7.4.
Be responsible for issued TxDOT security badges to personnel. TxDOT will be reimbursed at no
additional cost for lost, damaged and unreturned security badges. The designated TxDOT
representative will notify the vendor of the amount to be reimbursed.
7.5.
Provide all labor, materials and equipment necessary to meet the requirements of the specified
services throughout the term of the purchase order.
7.6.
Provide all the parts necessary for the fire extinguishers to be ready for use. All parts shall
conform to current industry standards.
7.7.
Provide a continuous on-site work force during regular working hours, until completion of
scheduled annual maintenance and inspection of all portable fire extinguishers have been
completed at all the locations listed on Attachment A – Locations.
7.8.
Have additional staff or subcontractors available to respond to multiple service requests
simultaneously, as requested by the designated TxDOT representative, on an as needed basis.
KEY PERSONNEL REQUIREMENTS: ST shall:
8.1.
Wear an identifying name badge with the company logo or a uniform with the personnel’s name
and company name or logo clearly marked on the uniform.
8.2.
Present and maintain a neat appearance at all times while on TxDOT property.
8.3.
Report to the designated TxDOT representative upon arrival at the job site to obtain an access
badge and return the access badge to the designated TxDOT representative before leaving the
job site.
8.4.
Wear the TxDOT issued access badge in a location on the uniform shirt or jacket where it is
visible at all times.
8.5.
Be fluent in English with the ability to receive, give and understand written and oral instructions.
8.6.
Communicate verbally in English, speaking in a manner used in most office environments.
8.7.
Not be excessively loud or use personal multi-media devices (i.e. portable radios, CD players or
MP3 players) while performing services for TxDOT.
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SPECIFICATION NO
*
TxDOT 936-34-42
REVISED: MAY 2015
9.
SERVICE REQUIREMENTS: The vendor shall:
9.1.
9.2.
9.3.
ANNUAL INSPECTION
9.1.1
Annually inspect, maintain and recharge each portable fire extinguisher at all the
building locations listed on Attachment A – Locations at a time selected by TxDOT.
9.1.2
Verify each portable fire extinguisher is fully charged and operable.
9.1.3
Advise the designated TxDOT representative and perform a hydrostatic test on each
portable fire extinguisher, as required by NFPA 10-Table 5A, latest edition.
9.1.4
Gauge pressures shall be in operable range.
9.1.5
Nozzles, discharge valves, and hoses shall be unobstructed, and lock pins and dated
tamper seals shall be in place.
9.1.6
Recharge dry chemical portable fire extinguishers if gross weight is less than
manufacturer’s recommendations.
9.1.7
Identify any Halon-type portable fire extinguishers in need of recharge. Only fill Halontype portable fire extinguishers at the request of TxDOT. TxDOT may decide to replace
the type of unit rather than refill.
ANNUAL MAINTENANCE AND REPAIR
9.2.1
Perform maintenance of portable fire extinguishers in accordance with the
manufacturer’s published service procedures, using only refill extinguishing agents
listed on the extinguisher or as recommended by the manufacturer.
9.2.2
Notify the designated TxDOT representative when any unit has been used or needs to
be replaced.
9.2.3
Only perform repairs on portable fire extinguisher if the cost of the repairs will not
exceed 50 percent of the current manufacturer’s list price for the same type of portable
fire extinguisher with identical capacity.
9.2.4
Furnish all repair and replacement parts including but not limited to lock pins, nozzles,
valves, seals, 0-rings, nitrogen cylinders, extinguishing agents, hoses, and adapters.
Parts furnished shall be matched to the manufacturer’s published requirements.
9.2.5
Replace Instruction labels as needed during inspection.
9.2.6
Complete all repairs at the vendor’s location.
ANNUAL RECHARGE: All recharging shall be performed by the vendor in compliance with
manufacturer’s authorized recharging procedures when regular or multi-purpose dry chemicals
are recharged. The extinguishing agent shall be completely discharged, valve assembly removed,
0-ring replaced or lubricated, threads and sealing surfaces cleaned, container emptied and then
filled with proper (free-flowing) agent, pressurized, sealed and locked. Recharge date shall be
marked on tag. Testing shall be in accordance with ANSI/UL 711 and UL 299, and NFPA 10.
The vendor shall also replace expellant cartridge when required on a wheeled dry chemical unit.
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SPECIFICATION NO
*
TxDOT 936-34-42
REVISED: MAY 2015
9.4.
INSPECTION AND MAINTENANCE TAGS: The vendor shall attach the Texas State Fire
Marshall approved labels or tags imprinted with the vendor name, address, telephone number,
and month and year maintenance was performed on each extinguisher when existing inspection
tags are replaced. This tag shall identify the person performing the service, indicate if recharging
was performed, and show the date the test was completed, per NFPA 10. Inspection tags shall
be all weather type tags.
9.5.
Notify the designated TxDOT representative immediately for replacement and mounting if vendor
identifies a mounted portable fire extinguisher of a type other than shown on the building plans at
any location. The vendor’s written report to the TxDOT representative shall include the type,
capacity and the locations of all the deficient fire extinguishers.
9.6.
SCHEDULING
9.7.
10.
11.
9.6.1
Annual inspections shall be performed at a date and time consistent with preestablished preventive maintenance schedules established by TxDOT. Each site
inspection shall be scheduled with the designated TxDOT representative at least three
working days in advance of the inspection date. Inspections, pick-ups, and returns of all
units shall be performed between the hours of 8:00 a.m. and 4:00 p.m., Monday through
Friday, except on federal and state observed holidays.
9.6.2
During the annual inspection, or as-needed, the vendor shall pick up and transport any
portable fire extinguisher that requires repair or recharging within 24 hours of
identification. The fire extinguishers shall be transported to the vendor’s location,
serviced, and returned to the original location within 48 hours of notification. Before
transporting any fire extinguishers, the vendor shall immediately replace the current fire
extinguisher with an identical fire extinguisher of equal or greater capacity.
Replacement fire extinguishers will be provided by TxDOT.
SERVICE COMPLETION CONFIRMATION: The vendor shall provide TxDOT written
confirmation that all portable fire extinguishers at each location have been identified, and tested
per the requirements stated in the specification, and an appropriate status tag attached to each
unit within 48 hours of completion of the service.
LOCATION(S)
10.1.
Location(s) of facilities are specified on Attachment A – Locations. TxDOT reserves the right to
add or delete facilities serviced under the purchase order. TxDOT will provide ten business days
written notice to the vendor for facilities to be deleted or of any additional facilities requiring
service within the same area or region.
10.2.
Building plan documents showing portable fire extinguisher locations will be available for review at
the post award meeting (Ref. Para. 23.), and during actual servicing by the vendor. Building plan
documents will not be released by TxDOT, nor reproduced, and shall remain in the care of the
designated TxDOT building maintenance employees at all times.
WARRANTY REQUIREMENTS
11.1.
PERFORMANCE WARRANTY: Work performed under the purchase order shall meet all
applicable standards and codes. The vendor shall guarantee all work included in the purchase
order against any defects in workmanship; and shall satisfactorily correct, at no cost to TxDOT,
any such defect that may become apparent within a period of one year after completion of work.
The warranty period shall commence upon date of acceptance by TxDOT.
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SPECIFICATION NO
*
TxDOT 936-34-42
REVISED: MAY 2015
11.2.
12.
MATERIAL WARRANTY: Materials provided under the purchase order shall be in current
production, as offered to commercial trade, and shall be of quality material. USED,
SHOPWORN, DEMONSTRATOR, PROTOTYPE, RECONDITIONED OR DISCONTINUED
MATERIALS ARE NOT ACCEPTABLE. Materials shall be warranted against material defects
and defects in workmanship for a period of not less than 12 months and shall cover 100% parts
and labor. The warranty period shall commence upon date of acceptance by TxDOT. If the
manufacturer’s standard warranty period exceeds 12 months, then the standard warranty period
shall be in effect. The vendor shall be ultimately responsible for the warranty. The vendor shall
provide the designated TxDOT representative with all manufacturers’ warranty documents upon
completion of service prior to leaving the job site.
VENDOR PERFORMANCE: Vendor performance will be monitored on a regular basis by TxDOT.
12.1.
TxDOT may consider the following performance by the vendor as unsatisfactory performance.
An unsatisfactory performance determination includes, but is not limited to:
12.1.1
One service “call back” to correct the same problem within 30 calendar days.
12.1.2
One instance within one year of vendor personnel assigned to an authorized service
call not having the state license and certification required to diagnose the problem and
perform the repair.
NOTE: Unsatisfactory performance will result in a negative vendor performance report,
or cancellation of the purchase order or both.
12.2.
13.
14.
An exceptional performance determination includes, but is not limited to:
12.2.1
Inspections completed early upon TxDOT member request.
12.2.2
Vendor commended for exceptional customer service, exceptional service provided.
BUILDING RESTRICTIONS
13.1.
PARKING: The vendor shall make arrangements with the designated TxDOT representative
prior to off-loading tools and equipment at the job site. The vendor shall park only in spaces
assigned by the designated TxDOT representative.
13.2.
RESTROOMS: Restrooms shall not be used for washing of tools and equipment.
13.3.
SECURITY: The vendor shall provide an updated list of all vendor personnel or subcontractors at
each job site and comply with all security measures required by TxDOT.
13.4.
ACCESS: The vendor shall make prior arrangements with the designated TxDOT representative
for access to the building(s) for performance of the service.
PERSONNEL CONTINUITY AND REPLACEMENT
14.1.
TxDOT recognizes that events beyond the control of the vendor such as the death, physical or
mental incapacity, long-term illness, or the voluntary termination of employment of the PM,
account manager, any key or respondent personnel, etc. will require the vendor propose a
replacement. In the event such a replacement is necessary, vendor agrees that personnel shall
not begin work on the project without prior written approval from TxDOT.
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SPECIFICATION NO
*
TxDOT 936-34-42
REVISED: MAY 2015
14.2.
If TxDOT determines the PM, a team member or other key personnel is unable to perform in
accordance with the service requirements or to communicate effectively; the vendor shall
immediately remove that person upon notification by TxDOT.
14.3.
Proposed replacement personnel shall meet minimum qualifications and have experience
comparable to the person(s) being replaced. Replacement personnel shall be provided at no
additional cost to TxDOT. TxDOT may reject any replacement if references or past working
performance is questionable or unfavorable. TxDOT will be the sole judge of the qualifications of
the proposed replacement personnel.
15.
VENDOR PERSONNEL SAFETY: The vendor shall provide all required safety equipment and instruct
personnel to observe all safety policies, rules and requirements at all times, including, but not limited to,
wearing hard hats, safety shoes, goggles, etc.
16.
SUBCONTRACTING
16.1.
Subcontractors providing service under the purchase order shall meet the same qualifications
and service requirements and provide the same quality of service required of the vendor.
16.2.
No subcontract under the purchase order shall relieve the primary vendor of responsibility for the
services.
16.3.
The vendor shall be the only contact for TxDOT and subcontractor(s).
16.4.
The vendor shall manage all quality and performance, project management, and schedules for
subcontractors. The vendor shall be held solely responsible and accountable for the completion
of all work for which the vendor has subcontracted.
16.5.
TxDOT retains the right to check subcontractor’s background and make a determination to
approve or reject the use of submitted subcontractor(s). Any negative responses may result in
disqualification of the subcontractor.
16.6.
TxDOT reserves the right to request the removal of vendor’s subcontractor staff deemed
unsatisfactory by TxDOT.
16.7.
Subcontracting shall be at the vendor’s expense.
16.8.
During the term of the purchase order, if the vendor determines a need for a subcontractor
change, TxDOT shall be notified in writing by the vendor within 15 calendar days of any proposed
change. The vendor shall be required to provide references and work history for any proposed
subcontractor to TxDOT. No change will be allowed without written authorization by TxDOT.
16.9.
SOLICITATIONS OVER $100,000: TxDOT will make an initial determination of whether
subcontracting is probable. It is the respondent’s determination to choose to subcontract any of
the work under this purchase order with a Texas certified Historically Underutilized Business
(HUB) or other businesses.
16.9.1.
If TxDOT has determined that subcontracting opportunities are probable, the class and
items in which HUBs may be registered will be noted in the solicitation.
16.9.2.
The respondent shall identify all proposed HUB and other subcontractors at the time of
response submittal. The required forms with video instructions can be found at the
following website: http://www.window.state.tx.us/procurement/prog/hub/hubsubcontracting-plan/
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SPECIFICATION NO
*
TxDOT 936-34-42
REVISED: MAY 2015
16.9.3.
RESPONSES THAT DO NOT INCLUDE A COMPLETED HUB SUBCONTRACTING
PLAN AS INDICATED ON THE SOLICITATION SHALL BE REJECTED PURSUANT
TO TEXAS GOVERNMENT CODE §2161.252(B).
16.10. HUB SUBCONTRACTING PLAN (HSP) PRIME CONTRACTOR PROGRESS ASSESSMENT
REPORT: After award of the purchase order, the vendor shall report all HUB and non-HUB
subcontractor information using the HSP Prime Contractor Progress Assessment Report form.
The report shall be submitted to the TxDOT contract manager monthly. The report shall be
submitted monthly even during the months the vendor is not invoicing TxDOT. All payments
made to subcontractors shall be reported. TxDOT may verify the amounts being reported as paid
by requesting copies of cancelled checks paid to subcontractors.
16.11. REVISING THE HSP DURING THE TERM OF THE PURCHASE ORDER: Vendors may need to
revise the original HSP submitted with the response during the term of the purchase order to add
additional subcontractors or change existing subcontractors. The additional subcontractor shall
be approved by TxDOT prior to beginning work. If the vendor is replacing a HUB subcontractor
with another HUB, no Good Faith Effort is required. If the vendor is replacing a HUB with a nonHUB, a Good Faith Effort is required and the rules which apply to notifying HUBs of the
subcontracting opportunity apply.
17.
TRAVEL: All travel and per diem shall be included in the unit price.
18.
CONFLICT OF INTEREST: The vendor, vendor’s personnel, and vendor’s subcontractor(s) shall affirm
not to have, nor acquire any interest during the term of the purchase order that would conflict in any
manner with the performance of the vendor’s obligations in regards to services authorized.
18.1.
18.2.
To avoid an appearance of a conflict of interest, any qualified non-TxDOT laboratory shall
perform only one of the following types of testing on the same project:
18.1.1.
Quality assurance verification testing.
18.1.2.
Quality control testing.
The vendor certifies and warrants that he or she and any relative to the first consanguinity (blood)
or affinity (marriage) have not been employed or an employee or contracted agent for the firm in
which he/she is performing inspections as required under the purchase order for a period not less
than five years from the effective date of the purchase order. Furthermore, the vendor certifies
and warrants that he or she and any relative to the first consanguinity (blood) or affinity
(marriage) have no financial interests of any kind in the firm in which he or she is performing
inspections as required under the purchase order. Violation of this provision may be grounds for
termination of the purchase order.
18.2.1.
First consanguinity (blood) is described as: A person is related to you by blood in the
first degree if the person is your: Mother or father, brother or sister, son or daughter.
18.2.2.
Affinity (marriage) is described as: A person who is: your spouse, or spouse’s mother
or father, brother or sister, son or daughter; your brother’s or sister’s spouse, son’s or
daughter’s spouse, step-mother or step-father.
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SPECIFICATION NO
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TxDOT 936-34-42
REVISED: MAY 2015
19.
20.
21.
INVOICING INSTRUCTIONS: The vendor shall provide:
19.1.
ORIGINAL INVOICE: A comprehensive and detailed invoice with reference to the line item on
the purchase order for each item charged. The original invoice shall be e-mailed to
FIN_Invoices@txdot.gov unless otherwise shown on the purchase order to ensure timely
payment and shall include the following:
19.2.
Complete purchase order number.
19.3.
Vendor Employer Identification Number (EIN).
19.4.
Date and time of service.
19.5.
Location of service.
19.6.
Technician’s name with hours totaled.
19.7.
An invoice requiring correction shall be re-submitted with a new invoice date.
TxDOT RESPONSIBILITIES: TxDOT will:
20.1.
Provide a contract manager.
20.2.
Provide a point of contact.
20.3.
Provide and mount all replacement fire extinguishers.
20.4.
Provide building access.
RESPONSE SUBMISSION:
21.1.
21.2.
22.
The following shall be submitted with the response. Failure by the respondent to submit the
documentation listed below will disqualify the respondent from further consideration.
21.1.1.
Original, signed, dated, and completed IFB
21.1.2.
Schedule 1 – Pricing
21.1.3.
Schedule 2 – Respondent Qualifications and Experience
21.1.4.
Schedule 3 – Key Personnel Qualifications
21.1.5.
HUB Subcontracting Plan (If applicable)
The following should be submitted with the response. Failure by the respondent to submit the
documentation listed below may disqualify the respondent from further consideration.
21.2.1.
Respondent References
21.2.2.
Copies of Certifications, Permits, Licenses
AWARD: TxDOT reserves the right to award a purchase order(s) to the company that provides the best
value to TxDOT in performance of this service. TxDOT may award to a single vendor, multiple vendors,
or use any combination that best serves the interest of TxDOT.
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SPECIFICATION NO
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TxDOT 936-34-42
REVISED: MAY 2015
22.1.
TYPES OF AWARD
22.1.1.
Single Award: One purchase order awarded to a single vendor.
22.1.2.
Multiple Award: A multiple award is the award of multiple purchase orders for the same
line item(s) from a single solicitation to two or more vendors to provide the same or
similar goods or services.
22.1.3.
Multi-tiered Award: Multi-tiered award sets the priority sequence for use of multiple
vendors. Multiple purchase orders are awarded for the same line item(s) from a single
solicitation to primary, secondary and tertiary vendors.
23.
POST AWARD MEETING: Vendor(s) may be requested to attend a post award meeting in person at a
location designated by TxDOT or via teleconference, within 7 calendar days after the award of the
purchase order. The purpose of the meeting is to discuss the terms and conditions of the purchase order
and to provide additional information regarding the purchase order. Vendor(s) and TxDOT shall identify
specific goals, strategies and activities planned for meeting particular program area objectives.
24.
CONTRACT ADMINISTRATION: Administration of the purchase order is the responsibility of TxDOT.
TxDOT Procurement Division staff will be responsible for administering the contractual business
relationship with the vendor.
24.1.
Any proposed changes to work to be performed, whether initiated by TxDOT or the vendor, must
receive final written approval in the form of a Purchase Order Change Notice signed by the
authorized TxDOT purchasing agent.
24.2.
Upon issuance of purchase order, TxDOT will designate an individual to serve as the Contract
Manager and point of contact between TxDOT and the vendor. The Contract Manager does not
have any express or implied authority to vary the terms of the purchase order, amend the
purchase order in any way or waive strict performance of the terms or conditions of the purchase
order. This individual’s contract management and contract administration responsibilities include,
but are not limited to:
24.2.1.
Monitoring the vendor’s progress and performance and ensuring services conform to
established specification requirements.
24.2.2.
Managing the financial aspects of the contract including approval of payments.
24.2.3.
Meeting with the vendor as needed to review progress, discuss problems, and consider
necessary action.
24.2.4.
Identifying a breach of contract by assessing the difference between contract
performance and non-performance.
24.2.5.
Other areas as identified by the Comptroller of Public Accounts Contract Management
Guide, latest edition.
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SPECIFICATION NO
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TxDOT 936-34-42
REVISED: MAY 2015
RESPONDENT REFERENCES
SOLICITATION NO. XXXXXXXXXXXXXXXX
RESPONDENT’S NAME
Page 1 of
Company Name:
Address:
City:
State:
Phone Number:
Fax Number:
Zip Code:
Point of Contact:
Date Services Performed:
Reference Response (to be filled in by TxDOT):
Company Name:
Address:
City:
State:
Zip Code:
Phone Number:
Fax Number:
Point of Contact:
Reference response:
Date Services Performed:
Company Name:
Address:
City:
State:
Zip Code:
Phone Number:
Fax Number:
Point of Contact:
Reference response:
Date Services Performed:
THIS PAGE OR A REASONABLE FACSIMILE SHOULD BE RETURNED WITH THE
RESPONSE. FAILURE TO RETURN THIS PAGE OR A REASONABLE FACSIMILE MAY
RESULT IN THE RESPONSE BEING CONSIDERED NON-RESPONSIVE. ANY NEGATIVE
RESPONSE(S) MAY RESULT IN DISQUALIFICATION OF THE RESPONSE.
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