Department of Human Resources s6

ATTACHMENT A—REVISED 2/1/2012

State of Maryland

Department of Human Resources

BID FORM

ADMINISTRATION: PRINCE GEORGES COUNTY OFFICE OF CHILD SUPPORT ENFORCEMENT

4235 28TH AVENUE, SUITE 135

TEMPLE HILLS, MD 20748

SERVICE REQUIRED: Provide 2 persons to perform Data Entry Services.

SOLICITATION NUMBER: CSEA/PGCOC/12-003-S

BIDDER NAME:

ADDRESS:

CITY, STATE, ZIP:

PHONE:

FAX:

FEDERAL ID:

EMPLOYEES / (A)
Hourly Rate / x(B)
Estimated Number of Hours* / =(C)
Amount of Bid
Training for Data Entry Persons / 10
Data Entry Person 1 / 1944
Data Entry Person 2 / 1944
TOTAL Not to Exceed Price

Used as basis for award

*Note: Number of hours is an estimate used for Bid preparation only and cannot be guaranteed.

Are you a Minority Business Enterprise (MBE) Vendor: Yes No

If yes, list MDOT State Certified MBE Registration Number:

Are you a Small Business Reserve (SBR) Vendor: Yes No

If yes, list DGS Small Business Reserve Registration Number:

Printed Name of Representative Authorized to Bind Prices and Bid:

(Signature) (Title) (Date)