2025/06/11 Council Agenda Packet

Page 15 of 23 FORM 4.01 SUPPLIER COMMITMENT AND INFORMATION REQUEST FOR PROPOSAL #2025-032 SODIUM HYPOCHLORITE Company Name: Company Address: City: State: ZIP: Tax ID #: UBI #: Legal status of supplier organization, i.e., corporation, partnership, sole proprietorship. Diversity Certification (if applicable): ☐ Disadvantaged Business Enterprise (DBE) ☐ Minority Business Enterprise (MBE) ☐ Women Business Enterprise (WBE) ☐ Minority Women Business Enterprise (MWBE) Certification number: 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 signing below, the Supplier agrees to be bound by all solicitation requirements and acknowledges receipt of all solicitation addenda, if any. In addition, Supplier certifies as following: (1) the undersigned is authorized to commit Supplier to this proposal and that the information herein is valid 90 days from this date, (2) all information presented herein is accurate and complete, (3) Supplier has had an opportunity to ask questions regarding this proposal and that those questions have been answered, and (4) this proposal is made without prior understanding, agreement, or connection with any other corporation, firm, or person submitting a proposal and is in all respects fair and without collusion or fraud. By signing below, the Supplier agrees that a contract will be formed between the City and Supplier if the City awards to the Supplier and issues a purchase order to the Supplier. The City-Supplier contract will include all parts of this solicitation, including without limitation all specifications and all standard purchase order terms and conditions. The contract will also include Forms 3.01, 3.02, 3.03, and 3.04 as filled out by Supplier. No terms or conditions or qualifications proposed or otherwise provided by Supplier in such Forms or elsewhere will be part of the contract unless the City in its sole discretion adds them to the contract by calling them out on the face of the City’s purchase order. This form shall be submitted as the proposal cover page. This form may be signed by any method: ink, pdf, e-sign or otherwise. Supplier agrees that its signature below is fully binding on Supplier. Authorizing Official Name: Authorizing Official Title: Authorizing Official Email: Authorizing Official Phone: Authorizing Official Signature and Date: