Public Psychological Services 10/29/2019

FORM 4.02 SUPPLIER COMMITMENT AND INFORMATION REQUEST FOR PROPOSAL #2019-039 PRE-EMPLOYMENT PSYCHOLOGICAL EVALUATIONS Company Name: Company Address: City: State: ZIP: Tax ID #: UBI #: Legal status of supplier organization, i.e., corporation, partnership, sole proprietorship. Website: City of Everett Business License # Supplier Contact Name (if different from Authorizing Official): Supplier Contact Title: Supplier Contact Email: Supplier Contact Direct Phone: Supplier Contact Address (If different from above): City: State: ZIP: By responding to this solicitation, the Supplier understands and agrees to be bound by all requirements and contract terms and conditions contained in this solicitation. By signing this form, the Supplier acknowledges receipt and understanding of any and all addenda issued for this solicitation. This form, signed by an individual authorized to legally commit the Supplier, shall be submitted as the cover page. The Supplier also certifies that: • I am authorized to commit my firm to this Proposal and that the information herein is valid for 120 days from this date. • That all information presented herein is accurate and complete and that the scope of work can be performed as presented in this proposal upon the City's request. • That I have had an opportunity to ask questions regarding this Proposal and that those questions have been answered. • That this Proposal response is made without prior understanding, agreement, or connection with any corporation, firm, or person submitting an offer for this Proposal and is in all respects fair and without collusion or fraud. Authorizing Official Name: Authorizing Official Title: Authorizing Official Email: Authorizing Official Phone: Authorizing Official Signature: 12