Moffitt Cancer Center Vendor Acknowledgement Form

Intent to Bid

SUBMIT BID TO:

BID NUMBER: RFP11-09-NMD
Linda Balter
Linda.balter@moffitt.org
MOFFITT CANCER CENTER BID TITLE: Corporate Compliance Clinical Trials
12902 MAGNOLIA DRIVE Quality Review Audit
MBC2-PUR
TAMPA, FLORIDA 33612
813-745-7642

VENDOR NAME: INTENT TO BID

Yes ______________ No _______________

VENDOR MAILING ADDRESS VENDOR REMITTANCE ADDRESS

TELEPHONE NUMBER VENDOR’S AUTHORIZED CONTACT FOR RFP

NAME
FACSIMILE NUMBER
E-MAIL

SUPPLIER DIVERSITY INFORMATION

Is your firm a “Minority, Woman-Owned, or Disadvantaged Business Enterprise” defined as a business concern engaged in
commercial transactions and is a least fifty-one (51%) percent minority or woman-owned, and whose management and
daily operations are controlled by such persons?

Yes __________ No __________

Is your firm certified as a “Minority, Woman-Owned, or Disadvantaged Business Enterprise”? If yes, please provide the
name of the certifying entity and certification dates:

Name of Certifying Entity ______________________________

Certification Date Begins _______________ ______________ Ends _____________________________

AUTHORIZED SIGNATURE PRINTED NAME AND DATE

I certify that this bid is made without prior understanding, agreement, or connection with any corporation, firm, or person submitting a bid for the same
materials, supplies or equipment, and is in all respects fair and without collusion or fraud. I agree to abide by all conditions of this bid and certify that I am
authorized to sign this bid for the bidder and that the bidder is in compliance with all requirements of the invitation to bid.