Open Market Request for Quotations BN FORM

REQUEST FOR QUOTATION

Contract Opportunities (SAM.gov)
NSN: 5120001692986

HAVE YOU UPDATED YOUR REPRESENTATIONS AND CERTIFICATIONS LATELY ON WWW.SAM.GOV?

IF NOT, BE SURE TO DO SO PRIOR TO CLOSING OF SOLICITATION.

PLEASE COMPLETE THE FOLLOWING INFORMATION:

1. OFFEROR:

Please provide pricing for the following NSN. See Terms & Conditions on following pages. Requirement

Requested
Quantity DARO

5120001692986

Manufacturer and Country of Quoted Price (EA)
Part Number
(Discount
Extended
Origin
Quoting
(COO)
Requested)
Quoted Price

This requirement consists of one order and will be shipping to:

NORFOLK VA 23511

$

$

NOTE: Full delivery addresses will either be disclosed at time PO is issued, or the vendor may be required to contact the GSA Transportation Department at [email protected] or NAVSUP at [email protected] to obtain additional shipping instructions.

2. TERMS OFFERED:

●
●
●

3. ADMINISTRATIVE COMPLIANCE:

NOTE: The below requirements marked with an (x) are to be completed and/or acknowledged. If any applicable blanks are not complete, the vendor’s quote will NOT be considered for award. ___X _ Provided all requested documents by the close date and time of the solicitation to include: •
•

All required Provision and Clause fill-ins submitted (as applicable):

•

•

•
___X
___X

My company is registered with SAM.gov and has provided responses to the provisions that require Offeror completion of information, representations, and certifications:

In accordance with Provision 52.240-90(c) (GSA Class Deviation RFO-2025-12), Covered telecommunications equipment or services representations. By submission of its offer, the Offeror represents that, after conducting a reasonable inquiry (1) It will not provide covered telecommunications equipment or services to the Government in the performance of any contract, subcontract or other contractual instrument resulting from this solicitation, except as waived by the solicitation, or as disclosed in paragraph (g); and (2) It does not use covered telecommunications equipment or services, or use any equipment, system, or service that uses covered telecommunications equipment or services, except as waived by the solicitation, or as Offeror certifies that they will comply with all requirements in Provision 52.240-91 (GSA Class

one yes should be selected.

SELF CERTIFICATION:

By signing below, you are certifying that the information submitted on this form is accurate and meets the requirements listed in the