Enclosure C - AMS-Form-043

PROCUREMENT AND PROPERTY MANAGEMENT DIVISION

BROOKHAVEN NATIONAL LABORATORY

Managed by Brookhaven Science Associates, LLC
under contract to the U.S. Department of Energy

Form No. AMS-Form-043
Revision: 2.0
Effective Date: 9/15/2026

APPROVED BY:

ACQUISITION MANAGEMENT SYSTEM FORM

Dedra Blood

Quotation/Proposal Pricing Sheet
Reference:

BSA Request for Quotation/Proposal No. 483335
Description: one (1) stripline kicker prototype

Attention:

Buyer/Contract Specialist: Mark Bryan

*Must be in U.S. Dollars and inclusive of all taxes, fees, customs, duties and other charges. This price shall remain firm for 60 days.
Delivery is FOB Destination.
Payment terms are Net 30 (Large or Foreign Businesses), Net 10 (Small Businesses) Days.

*Company’s Export Control Point of Contact (POC):
*Phone #:
*Email Address:
*Required if country of origin or manufacture is located outside of the U.S.

Date Printed 10/20/2026

Concurrence:
By signing this Quotation/Proposal Pricing Sheet, our firm hereby acknowledges and agrees to BSA's requirements and delivery schedule and agrees to provide the resources necessary to meet BSA's delivery schedule. We affirm we are registered in SAM and our representations and certifications as well as our small business size status (if applicable) are current and complete. Additionally, please certify the following: Item commercial status. Check one of the following by clicking the ☐ next to the associated option: ☐ Commercial item as defined in FAR 2.101
☐ Non-commercial item
Can you meet delivery timeline? If yes, check this box: ☐ If not, please provide your forecasted delivery date:
Notice is hereby provided that BSA may disclose offeror proposals to U.S. Government personnel for review. In such case, BSA will furnish the proposal to the Government with any confidentiality legends included by the Offeror, but BSA is not responsible for any subsequent disclosure by the U.S. Government.

Certification: By signing this Quotation/Proposal Pricing Sheet, our firm hereby acknowledges and agrees to BSA's Terms and Conditions, as incorporated into the solicitation and attached documents.

Date Printed 10/20/2026