Appendix L - Proposal Submission form

Proposal Submission Form

PROPOSAL SUBMISSION FORM RFP No. RFP-001-A-08-0369-C

I (we), the undersigned, hereby declare that I am (we are) the only person(s) interested in this proposal; that it is made without any connection to any other person making any proposals for the same work; that no person representing or employed by the State of Connecticut has a direct or indirect financial interest in this proposal, or in any contract which may be made as a result of it, or in any profits expected to arise therefrom; that this proposal is made without directly or indirectly influencing or attempting to influence any other person or corporation to propose or to refrain from proposing or to influence the amount of the proposal of any other person or corporation; that this proposal is made in good faith without collusion or connection with any other person proposing for the same work. I (we) hereby certify that I (we) am (are) authorized to submit this proposal on behalf of my (our)company.

ALL INFORMATION BELOW MUST BE COMPLETED; ALL PROPOSALS MUST BE SIGNED

Company Name:_______________________________________________________

(As it appears on corporate seal if applicable)

FEIN # OR SOCIAL SECURITY #________________________________________

Address: ________________________________________________________

________________________________________________________

________________________________________________________

Telephone Number: (____)______________________

Signature: ___________________________________

Name: ________________________________

Title: _________________________________

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