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Service Contract

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SERVICE CONTRACT

REQUEST DATE:

2. NAME OF DEPARTMENT:

CONTACT PERSON:

3. Service:

4. Due Date:

5. Time Due:

6. Telephone:

Fax:

Proposals should be sent by the following method:

7. MAIL OR FAX PROPOSALS TO:

Name: ________________________________________________________

Address: ________________________________________________________________

Fax #_____________________

____________________________________________________________________________________________________________

The bottom portion of this form is to be completed by the vendor.

Equal Employment Opportunity – All parties must be in compliance with executive order 11246 of September 24, 1965 as amended by

executive order 11375 of October 13, 1967.

STATEMENT OF NON-COLLUSION AND NON-CONFLICT OF INTEREST

I hereby swear (or affirm) under penalty for false swearing as provided by:

That attached Request For Proposal has been submitted without collusion with, and without any agreement, understanding or planned

common course of action with, any other vendor of materials, supplies, equipment or services described in the Request For Quotation

designed to limit independent competition.

That the proposer is legally entitled to enter into the contract with the _____________________________, and is not in violation of

any prohibited conflict of interest, including those prohibited by the provisions of State law.

That I have fully informed myself regarding the accuracy of the statements made above.

In submitting this quotation, it is expressly agreed that upon proper acceptance by ______________________, of any or all items bid, a

contract shall thereby be created with respect to the services accepted.

SIGNED BY:______________________________________TELEPHONE:____________________FAX:________________

PRINT NAME:______________________________________

FIRM:_________________________________________________________________________________________________

ADDRESS:_____________________________________________________________________________________________

CITY:_____________________________STATE:_____________________ZIP CODE:_____________

Service Contract

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