County Of Orange, NY

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1 Request for Quotation County Of Orange, NY REQUEST FOR QUOTATION Please submit your response to County of Orange, NY Cosh, Michael Orange County Dept of General Services 15 Matthews St, Suite 101 Phone: Fax: When submitting your proposal please include the following information Your Company Name Address Preparer's Contact Information Response Valid Until This document has important legal consequences The information contained in this document is proprietary of It shall not be used, reproduced, or disclosed to others without the express and written consent of 1 Header Information 11 General Information Title ArjoHuntleigh Tub Repair Parts for Valley View Close Date 25-SEP :00:00 Time Zone Eastern Time Note TERMS AND CONDITIONS: - THE COUNTY DESIRES THAT YOUR QUOTE BE "DELIVERED" PRICING IF YOUR QUOTED PRICE DOES NOT INCLUDE SHIPPING, HANDLING OR ANY OTHER ORDER PROCESSING FEES IN THE COST OF THE ITEM YOU MUST ACCURATELY PROJECT THESE COSTS AND INDICATE THEM ON THIS QUOTATION FORM IN THE NOTE TO BUYER SECTION IF THERE IS NO INDICATION OF ADDITIONAL CHARGES OR IF THEY ARE GROSSLY MISCALCULATED, THE COUNTY WILL NOT BE HELD LIABLE FOR THESE CHARGES IF THEY ARE ADDED TO THE INVOICE - PRICE MUST BE GUARANTEED FOR A MINIMUM OF 30 DAYS AFTER QUOTE CLOSE DATE - ALL RESPONSES MUST BE SUBMITTED ON THIS FORM YOUR INTERNAL QUOTE FORM CAN BE SUBMITTED AS A SUPPLIMENT BUT THIS FORM MUST ALSO BE COMPLETED, SIGNED AND SUBMITTED - AWARD BASIS IS ALL-OR-NONE THIS FORM CAN BE RETURNED BY FAX TO UNLESS INSTRUCTED OTHERWISE Page 1 of 5

2 12 Terms Request for Quotation Ship To Address Please use the ship-to address listed below Bill To Address Finance - Accounts Payable PO Box 407 Payment Terms FOB Freight Terms 13 Response Rules This negotiation is governed by all the rules checked below Suppliers are allowed to respond to selected lines Suppliers are required to respond with full quantity on each line Suppliers are allowed to provide multiple responses Buyer may close the negotiation before the Close Date Buyer may manually extend the negotiation while it is open 2 Price Schedule 21 Lines Information Line Disinfectant Ferule Kit, item # PS0416 Push Fit Air Jet Assembly, item # PS1463 DU8Auto fill solenoid Kit, item # PS1450 Circuit Board, item # Shower Head, item # PS1420 Shower Head White, item # PP0948 Hand Control, item # PS0453 Control Knob, item # PC0805 Door Lock, item # FF0806 Floor Drain Assembly, item # PS1246 Ground Shipping Item, Rev Quantity Unit Requested 6 Each 8 Each 2 Each 2 Each 2 Each 4 Each 4 Each 12 Each 4 Each 2 Each 1 Each Quantity Quoted Unit Price Amount Promised Date 22 Line Details 221 Line 1 Disinfectant Ferule Kit, item # PS0416 Page 2 of 5

3 Request for Quotation Line 2 Push Fit Air Jet Assembly, item # PS Line 3 DU8Auto fill solenoid Kit, item # PS Line 4 Circuit Board, item # Line 5 Shower Head, item # PS Line 6 Shower Head White, item # PP Line 7 Hand Control, item # PS0453 Page 3 of 5

4 Request for Quotation Line 8 Control Knob, item # PC Line 9 Door Lock, item # FF Line 10 Floor Drain Assembly, item # PS Line 11 Ground Shipping Page 4 of 5

5 Request for Quotation X Notes to Buyer XX Supplier Signature DATE COMPANY NAME NAME AND TITLE (Must be printed) SIGNATURE Page 5 of 5

6 Division of Purchase Edward A Diana County Executive PO Box 218, 255 Main Street 3 rd Floor GOSHEN, NEW YORK TELEPHONE: FAX NUMBER: Thank you for your interest in becoming a registered supplier with Orange County Government The attached forms are designed to help you provide Orange County with all of the information we should need to get you set up in our data base If you are already a registered supplier and are using these forms to request a change to your existing information, thank you for you efforts to keep our records current Please note: Registering as an Orange County Supplier will not automatically register you with Hudson Valley Municipal Purchasing Group, or visa versa For more information on the Hudson Valley Municipal Purchasing Group please contact this office at the address information above Although the forms are basically self-explanatory, some areas can be confusing Hopefully the following elaboration will be helpful to you Supplier Name: Normally this is the name of your company, such as ABC Corporation However, in the instances where you are applying as a Do Business As (DBA) you should enter the DBA name in this field, which corresponds with DBA name on the Orange County Substitute W-9 Form which is also attached Taxpayer ID Number: This is your Employer Identification Number -or- your Social Security number, depending on what you enter in the Taxpayer Identification Number field on the attached Orange County Substitute W-9 Form Correspondence, Purchasing Address: This should be the address you want any purchase orders mailed to, or for general correspondence Payment, Remittance Address: This should be the address that all payments for goods and/or services provided by you or your company are to be mailed to Address for Solicitations Only : This address should be completed only if you desire to have pricing solicitations, also known as RFQ s, sent to an address other than the correspondence address This is normally the address used by sales persons who represent a company For example, John Smith is the sales representative for ABC Corporation and he desires to have solicitations sent directly to him rather than the main office of the company Contact Information: The name and telephone number of the person completing the form is required Although it is not required, supplying a valid address may prove to be valuable to you as a supplier in the future For assistance with completing the Orange County Substitute W-9 Form, please contact this office or visit our website at wwworangecountygovcom/purchasing and look under Supplier Information - Forms and Instructions Thank you for your interest in doing business with Orange County rev wwworangecountygovcom/purchasing

7 Supplier Application Form Thank you for your interest in doing business with Orange County Government Please supply all of the requested information on this form so that our records will be accurate When you have completed the form and the accompanying Orange County substitute W9 form please send them to the Division of Purchasing by mail, fax, or County Department Contact: Return completed forms to: Department: Orange County Division of Purchasing Telephone: Name: PO Box 218, 255 Main Street Fax Number: Telephone: Goshen NY PLEASE PRINT OR TYPE ALL INFORMATION Supplier Name (if this is a DBA, the DBA name must appear here and match the DBA stated on the substitute W9 form) Taxpayer ID Number New Supplier Change to existing record One of these boxes must be checked Correspondence, Purchasing Address Address Line1 Address Line 2 Address Line 3 Address Line 4 City State Zip Code Tel Area Code Tel number Fax Area Code Fax number Payment, Remittance Address Address Line1 Address Line 2 Address Line 3 Address Line 4 Same as above City State Zip Code Tel Area Code Tel number Fax Area Code Fax number Address for Solicitations Only (if applicable) Address Line1 Address Line 2 Address Line 3 Address Line 4 Same as above City State Zip Code Tel Area Code Tel number Fax Area Code Fax number Contact Information ( address must be included if supplier desires to take advantage of certain internet interactions with Orange County) Contact First Name Middle Last Contact Address Tel Area Code Tel number Fax Area Code Fax number PLEASE NOTE: THE ATTACHED ORANGE COUNTY SUBSTITUTE W9 FORM MUST ALWAYS BE COMPLETED AND SUBMITTED WITH THIS FORM TO THE ADDRESS STATED ABOVE IF IT IS NOT, THE APPLICATION WILL BE REJECTED AND YOU WILL NEED TO RE- APPLY rev

8 Orange County Substitute W-9 Form Request for Taxpayer Identification Number & Certification Please complete the following information We are required by law to obtain this information from you when making a reportable payment to you If you do not provide us with this information, you may be subject to a federal income tax withholding and may be subject to a $50 penalty imposed by the IRS under section 6723 Use this form if you are a US person (including a US resident alien) If you are a foreign person, complete and submit the appropriate IRS Form W-8 available at wwwirsgov See Pub 515 Please type or print clearly (For assistance in completing this form, you can refer to the instructions found on IRS Form W-9 available at wwwirsgov) Type of Request New Vendor OR Change: TIN Previous TIN: Effective Date: (check all that apply): Legal Entity Name Tax Address Entity Type Taxpayer Identification Number (TIN) (Provide only one nine-digit number) Social Security Number (SSN) Employer Identification Number (EIN) Legal Entity Name (As shown on your income tax return; must match SSN or EIN given Individual or Sole Proprietor enter owner s name) Business, Trade, Doing Business As (DBA) Name (if different from legal entity name) Tax Correspondence Address / Contact (address where tax information will be mailed): Address Address City State Zip Code Address Phone Number ( ) Fax Number ( ) Primary Contact Payment Requests are Primarily for: Legal Services Medical / Health Care / Veterinary Services Other Service (specify): Entity Type (must select one of the following): Individual Sole Proprietor or Sole Proprietor organized as LLC or PLLC Trust or Estate Partnership, LLP, or Partnership organized as LLC or PLLC Corporation or LLC, PLLC organized as a corporation providing health care, medical, veterinary, or legal services Commodities (products) Rent/Lease (equipment, buildings, etc) Real Estate Transaction (sale of easement, land, building, etc) Other (specify): Exempt Payee Corporation or LLC, PLLC organized as a corporation NOT providing health care, medical veterinary, or legal services Tax Exempt Organization under 501(a) (includes 501(c) (3)) US Government, a state, a possession of the US or any of their political subdivisions or instrumentalities Certification Under penalties of perjury, I certify that: 1 The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2 I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3 I am a US person (including a US resident alien) Certification instructions You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return For real estate transactions, item 2 does not apply For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must provide your correct TIN The Internal Revenue Service does not require your consent to any provision of this document other than the certification required to avoid backup withholding Signature of US Person Title Date Print the name above: Orange County Substitute W-9 3/6/2009

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