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Category 2: Sensitive information <br />Page 15 of 23 Category 2: For official use only / disclosure permissible by law. <br />F ORM 4.01 SUPPLIER COMMITMENT AND INFORMATION <br />REQUEST FOR PROPOSAL #2023-096 BIOXIDE® SUPPLY AND SERVICES <br /> Company Name: <br />Company Address: <br />City: State: ZIP: <br />Tax ID #: UBI #: <br />Legal status of supplier organization, i.e., corporation, partnership, sole proprietorship. <br />Diversity Certification (if applicable): ☐ Disadvantaged Business Enterprise (DBE) ☐ Minority Business Enterprise (MBE) ☐ Women <br />Business Enterprise (WBE) ☐ Minority Women Business Enterprise (MWBE) Certification number: <br />Website: City of Everett Business License # <br />Supplier Contact Name (if different from Authorizing Official): Supplier Contact Title: <br />Supplier Contact Email: Supplier Contact Direct Phone: <br />Supplier Contact Address (if different from above): <br />City: State: ZIP: <br />By responding to this solicitation, the Supplier understands and agrees to be bound by all requirements and contract <br />terms and conditions contained in this solicitation. By signing this form, the Supplier acknowledges receipt and <br />understanding of any and all addenda issued for this solicitation. This form, signed by an individual authorized to legally <br />commit the Supplier, must be submitted as the cover page. <br />The Supplier also certifies that: <br />• I am authorized to commit my firm to this Proposal and that the information herein is valid for 60 days from this date. <br />• That all information presented herein is accurate and complete and that the scope of work can be performed as presented in this <br />proposal upon the City’s request. <br />• That I have had an opportunity to ask questions regarding this Proposal and that those questions have been answered. <br />• That this Proposal response is made without prior understanding, agreement, or connection with any corporation, firm, or person <br />submitting an offer for this Proposal and is in all respects fair and without collusion or fraud. <br />This form may be signed by ink signature, copy of ink signature, copy of signature, e-signature or any other form of <br />signature. By submitting this bid, the bidder agrees that its signature will have the same legal effect as an original ink <br />signature. <br />Authorizing Official Name: Authorizing Official Title: <br />Authorizing Official Email: Authorizing Official Phone: <br />Authorizing Official Signature and Date: