Specifications

BIDDER DECLARATION
1. Prime bidder information (Review attached Bidder Declaration Instructions prior to completion of this form):
a. Identify current California certification(s) (MB, SB, SB/NVSA, DVBE): ____________ or None ____ (If “None”, go to Item #2)
b. Will subcontractors be used for this contract? Yes ___ No ___ (If yes, indicate the distinct element of work
your firm will perform in this contract
e.g., list the proposed products produced by your firm, state if your firm owns the transportation vehicles that will deliver the products to the State,
identify which solicited services your firm will perform, etc.). Use additional sheets, as necessary.
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
c. If you are a California certified DVBE: (1) Are you a broker or agent? Yes ___ No ___
(2) If the contract includes equipment rental, does your company own at least 51% of the equipment
provided in this contract (quantity and value)? Yes ___ No ___ N/A ___
2. If no subcontractors will be used, skip to certification below. Otherwise, list all subcontractors for this contract. (Attach additional pages if necessary):
Subcontractor Name, Contact Person, Subcontractor Address CA Certification Work performed or goods provided Corresponding Good 51%
Phone Number & Fax Number & Email Address (MB, SB, DVBE or None) for this contract % of bid price Standing? Rental?
Solicitation Number_____________________
CERTIFICATION: By signing the bid response, I certify under penalty of perjury that the information provided is true and correct.
State of California—Department of General Services, Procurement Division
GSPD–05–105 (EST 8/05)
Page_____ of _____
Bid 6000001312
State of California
11/14/2013 2:35 PM
p. 140