Specifications

STATE OF CALIFORNIA DEPARTMENT OF CORRECTIONS AND REHABILITATION
OBS 555 (02/11)
Non-Small Business
Preference Request and Subcontractor Acknowledgement
Name of Bidding Firm / Prime Contractor CDCR IFB or RFP Number:
Total Dollar Value of Subcontractor Use CDCR Bid Number:
This document confirms and acknowledges that the firm named below agreed to be identified by a bidding firm as a
proposed small business or microbusiness (SB/MB) subcontractor or supplier for a CDCR agreement.
Subcontractor acknowledgements:
A. The subcontracting firm named herein has committed to perform or provide services/labor or supplies equal to a
percentage of the total bid/cost proposal price submitted by the bidding firm named above.
B. The subcontracting firm named herein acknowledges the total dollar value of claimed participation identified above.
C. The subcontracting firm named herein agrees to provide the following subcontracted services/labor or supplies under
the resulting contract if the bidding firm named above receives the contract award:
Provide a brief description in the box below of the commercially useful function(s) that the subcontractor/supplier identified
herein will provide or supply. Attach additional page(s) if necessary.
The subcontracting firm named herein understands it is its sole responsibility to contact the bidding firm named above to
learn if the Proposer was awarded the contract pursuant to the referenced bid number and to confirm its subcontract
agreement. If the bidding firm named above receives an award based in part on non-small business subcontractor
preference, the bidding firm/contractor is obligated to use each SB/MB subcontractor or supplier identified in its proposal
unless a subcontractor substitution is requested after contract execution pursuant to Public Contract Code Section 4107
and Title 2 California Code of Regulations Section 1896.10.
The person signing below certifies the information supplied on this form is true and accurate to the best of their knowledge
and agrees to allow the State to confirm this information, if deemed necessary.
Net Dollar Value of SB/MB
Subcontractor Agreement:
Total SB/MB
Percentage:
SB/MB Certification #: SB/MB Certification
Expiration Date:
Name of Proposed Subcontractor/Supplier: Date Signed:
Street Address: City: State: Zip Code:
Telephone Number:
( )
SB/MB E-mail Address (if applicable):
SB/MB Federal Employer ID (FEIN) #:
Printed/Typed Name: Title:
Signature of Subcontractor/Supplier Representative:
For State Use Only
Information Verified by:
Date:
Bid 6000001312
State of California
11/14/2013 2:35 PM
p. 132
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