Supplier Qualification Questionnaire

SUPPLIER QUALIFICATION QUESTIONNAIRE

RECITALS

WHEREAS, Client Name: desires to evaluate Supplier for the supply of goods and/or services described in the Scope of Work below; and

WHEREAS, Supplier Name: represents that it has the experience, capacity and qualifications necessary to fulfill Client's requirements and agrees to provide the information requested herein for evaluation and contractual purposes.

WHEREAS, the Parties intend for information provided in this Questionnaire to form the basis for contract negotiations and to be relied upon by Client in determining Supplier's eligibility and classification.

SUPPLIER INFORMATION

Corporation LLC Partnership Proprietor

SCOPE OF WORK

Describe in detail the goods and/or services Supplier is qualified to provide and any limitations or exclusions to Supplier's offerings:

PAYMENT TERMS

Contracted Price or Estimated Monthly Spend: $

Late Payment Fee:

TERM AND TERMINATION

Agreement Effective Date: . Agreement Expiration Date: .

Termination for Convenience: Either party may terminate this agreement upon written notice delivered at least days prior to the intended termination date.

Termination for Cause: Either party may terminate immediately for material breach that remains uncured for a period of thirty (30) days after written notice of such breach. Supplier shall remain liable for obligations and damages arising prior to termination.

INSURANCE, SAFETY & QUALITY

Does Supplier maintain commercial insurance in amounts sufficient for the proposed scope?   Yes   No

COMPLIANCE AND REPRESENTATIONS

Supplier represents and warrants that it is in compliance with all applicable laws, regulations and permits necessary to perform the services or supply the goods described in the Scope of Work. Supplier further certifies that the information provided in this Questionnaire is true, complete and accurate to the best of Supplier's knowledge, and that Supplier will promptly notify Client of any material change in this information.

Yes   No

CONFIDENTIALITY

All information exchanged between the Parties in connection with evaluation, negotiation and performance shall be considered Confidential Information. Each party agrees not to use Confidential Information for any purpose other than performance under a resulting agreement and to protect such information with at least the same degree of care it uses to protect its own confidential information, but not less than reasonable care. Confidential Information does not include information which is publicly known through no fault of the receiving party or which is rightfully received from a third party without restriction.

GOVERNING LAW

This Questionnaire and any resulting agreement shall be governed by and construed in accordance with the laws of the State of , without regard to its conflict of laws principles.

ENTIRE AGREEMENT

This Questionnaire, together with any attachments, exhibits and subsequent written agreements executed by the Parties, constitutes the entire agreement between the Parties with respect to the subject matter hereof and supersedes all prior and contemporaneous proposals, negotiations, representations and agreements, whether written or oral. Any modifications must be made in writing and signed by authorized representatives of both Parties.

CERTIFICATION & AUTHORIZATION

By signing below, Supplier certifies that it is authorized to provide the information herein, that the information is accurate and complete, and that Supplier authorizes Client to verify references, credit history and other information as necessary to evaluate Supplier's qualifications. False statements may result in disqualification from current and future opportunities and may subject Supplier to liability for damages.

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