Jacket: 604-908

Title: FY’19 SY’19 4HSS FIRST CONTROL & UNIVERSAL GENDER SELF-MAILERS

Agency: DEPARTMENT OF DEFENSE

Bid Opening: May 14, 2019 at 2:00 PM

Bid Terms Discounted Total

Monarch Litho, Inc. $204,402.00 2.0% 20 days $200,313.96

Contractor Name
Specifications by MW Jacket: 604-908

Reviewed by: DR Department of Defense

Page 1 of 9 Req: 9-240439G 

BIDS SHALL BE PUBLICLY OPENED AT 2:00 P.M., PREVAILING PHILADELPHIA, PA TIME, ON

May 14, 2019.

ANY QUESTIONS BEFORE AWARD CONCERNING THESE SPECIFICATIONS CALL MELITA WEBB 

AT (215) 364-6465 (Ext. 5). NO COLLECT CALLS.

SPECIFICATIONS

U.S. Government Publishing Office (GPO)

Southampton Office Park

Suite A-190

928 Jaymor Road

Southampton, Pennsylvania 18966

BIDDERS, PLEASE NOTE: GPO has issued a new GPO Publication 310.2, GPO Contract Terms -

Solicitation Provisions, Supplemental Specifications, and Contract Clauses (Rev 1-18). Prospective bidders

should carefully read this publication as the applicable terms within become an integral part of this contract. The 

document is posted at https://www.gpo.gov/how-to-work-with-us/vendors/forms-and-standards along with a list 

of major revisions.

GPO Contract Terms (GPO Publication 310.2) - https://www.gpo.gov/pdfs/vendors/sfas/terms.pdf

GPO QATAP (GPO Publication 310.1) – https://www.gpo.gov/docs/default-source/forms-and-standards-files-forvendors/qatap.pdf

The GPO 910 “BID” Form is no longer required. Bidders are to fill out, sign/initial, and return page 9.

PRODUCT: A 2 Version “Self-Mailer” printed in 4 color process, Pantone 296, Pantone 187 plus Matte 

Aqueous Coating requiring folding and three (3) clear wafer seals.

QUALITY LEVEL: 1 Quality Assurance Through Attributes (GPO PUB 310.1, effective May 1979 (Rev. 8-02) 

applies.

QUANTITY: 1,565,000 FIRST SELF-MAILER FIRM

 

 2 Version/Lots

 VERSION A – Control – (Code: FSC19) – 1,090,000 

 VERSION B – Universal Gender – (Code: FSG19) – 475,000

 

PLUS: 200 Quality Assurance Sample (100 packages of each Version) ( 50 Sealed and 50 Not Sealed)

 10 Department Sample Packages for each Version

TITLE: FY’19 SY’19 4HSS FIRST CONTROL & UNIVERSAL GENDER SELF-MAILERS

CONTROL NUMBER: 1182173

GOVERNMENT TO FURNISH: 1 CD InDesign for Version A and B; 1 set of laser proof sheets for each 

Version, 2 previous similar samples to follow for bindery and color for each Version; Labeling and Marking 

Specs.; GPO 905 labels.

PREFLIGHT: Prior to image processing, the contractor shall perform a basic check (preflight) of the furnished

media and publishing files to assure correct output of the required reproduction image. Any errors, media 
604-908 Page 2 of 9

damage, or data corruption that might interfere with proper file image processing must be reported to 

mwebb@gpo.gov.

CONTRACTOR TO FURNISH: All materials and operations, other than those listed under "Government to 

Furnish," necessary to produce the product(s) in accordance with these specifications.

PRESS SHEET INSPECTION

The contractor must notify the GPO of the date and time the (proof, press sheet, bindery, or other) inspection can 

be performed. In order for proper arrangements to be made, notification must be given at least 72 workday(s) 

prior to the inspection. Notify the U.S. Government Publishing Office, at (215) 364-6465 x 5. Telephone calls 

will only be accepted between the hours of 8:00 a.m. and 2:00 p.m., prevailing Eastern Time, Monday through 

Friday. 

PRESS SHEET INSPECTION: Final make-ready press sheets will be inspected and approved at the contractor’s 

plant for the purpose of establishing specified standards for use during the actual press run. Upon approval of the 

sheets, contractor is charged with maintaining those standards throughout the press run (within QATAP tolerances 

when applicable) and with discarding all make-ready sheets that preceded approval. See GPO Publication 315.3 

(Guidelines for Contractors Holding Press Sheet Inspections) issued January 2015. NOTE: A press sheet 

inspection is for the purpose of setting specific standards that are to be maintained throughout the entire run. It 

does not constitute a prior approval of the entire run.

Press sheets must contain control bars for each color of ink on the sheet. Control bars must be placed parallel to 

the press ink rollers. The control bars (such as BRUNNER, GATF, GRETAG, or RIT) must show areas 

consisting of 1/8 x 1/8 minimum solid color patches; tint patches of 25, 50, and 75%; dot gain scale; slur targets; 

two-color overprint ink trapping targets and gray balance patches for process color (if applicable). These areas 

must be repeated across the entire press sheet.

Viewing Light: Press sheets will be viewed under controlled conditions with 5000 degrees Kelvin overhead 

luminaries. The viewing conditions must conform to ISO 3664-2009; a viewing booth under controlled conditions 

with 5000 degrees Kelvin overhead luminaries with neutral gray surroundings must be provided.

NOTE: See Contract Clause, paragraph 14(e) (1), Inspections and Tests of GPO Contract Terms (GPO 

Publication 310.2, effective December 1, 1987 (Rev. 6-01)). When supplies are not ready at the time specified by 

the contractor for inspection, the Contracting Officer may charge to the contractor the additional cost of the 

inspection.

To maintain the required quality, the Government reserves the right to inspect the press sheets at the contractor's 

plant on any workday during the contractor's regular working hours. When press inspection is requested, it must 

be scheduled during contractor's first and/or second shifts ONLY.

The contractor must not print prior to receipt of an "OK to Print" during the Press Sheet Inspection.

NOTE: Upon completion of this order, if there were any changes, or if there were no changes to the furnished 

files, the contractor MUST furnish final production native files (digital deliverables) along with the furnished 

material. The digital deliverables MUST be an exact representation (reflecting any such changes as “AA’s 

retouching, etc., that were performed on the files prior to printing the end product), and MUST be returned/sent 

on the same type media or storage as was originally furnished. Any other media type than those furnished are 

unacceptable, unless specified otherwise by the Government. Both the original furnished files, and the digital 

deliverables (the final digital download mechanical of the actual printed product; these electronic files are to be 

stored/filed for Agency records).

APPROVAL: The contractor must begin production of the publication only after receiving, in writing, the 

statement "approved for production". If a press inspection is requested, approval for production will be given 

during the inspection. 
604-908 Page 3 of 9

The contractor must not print prior to receipt of an "OK to Print" during the Press Sheet Inspection.

PROOFS

PROOFS EACH VERSION: *5 high resolution proof sets (as described below), **4 constructed digital content 

proofs, 5 stock samples. Ink drawdowns for each pantone for each color version. Low-res PDF file for all 

components of all versions to (Jackie McGowan) only.

***5 set(s) of digital one-piece composite laminated halftone proofs on the actual production stock (Kodak 

Approval, Polaroid PolaProof, CreoSpectrum, or Fuji Final Proof) with a minimum resolution of 2400 x 2400 dpi.

At contractor’s option, (5) set(s) of inkjet proofs that are G7 profiled and use pigment-based inks may be 

submitted in lieu of digital one-piece composite laminated halftone proofs. A proofing RIP that provides an option 

for high quality color matching such as Device Links Technology and/or ICC Profiles Technology, and meets or 

exceeds industry tolerance to ISO 12647-7 standard for Graphic Technology (as of 2016 and future amendments) 

must be utilized. Proofs must be ripped and sent at plate resolution (minimum of 2400 x 2400 dpi). If using a 1 bit 

tiff, the tiff must be made at a minimum of 2400 dpi. Output must be a minimum of 2400 x 1200 dpi on a 

GRACoL or SWOP certified proofing media. Proofs must contain both of the following to be evaluated for 

accuracy: 3-tier color control strip: IDEAlliance ISO 12647-7 2013(i1), and the GPO Resolution target found at: 

www.gpo.gov/gporestarget.pdf. NOTE: If a contractor chooses this proof option, prior evaluation and approval 

of this proofing method must be provided by GPO, Quality Control for Published Products, to ensure that the final 

product will be produced in accordance with contract specifications. See instructions at:

https://www.gpo.gov/docs/default-source/forms-and-standards-files-forendors/qlsamples6f200c30b44a64308413ff00001d133d.pdf. Failure to obtain this evaluation and approval may be 

cause for the job to be rejected should the final product not match the proofs for color.

Proofs must contain color control bars (such as Brunner, GATF, GRETAG, or RIT) for each color of ink on the 

sheet. Control bars must be placed parallel to the press’s ink rollers and must show areas consisting of minimum 

1/8 x 1/8” solid color patches; tint patches of 25, 50 and 75%; dot gain scale; and gray balance patches for process 

color (if applicable). These areas must be repeated consecutively across the sheet.

The make and model number of the proofing system utilized shall be furnished with the proofs. These proofs must 

contain all elements, be in press configuration, and indicate margins. Proofs will be used for color match on press. 

Direct to plate must be used to produce the final product with a minimum of 2400 x 2400 dpi. 

Pantone colors may be substituted with a similar color (with the exception of process yellow) but may not be built 

out of the four process colors. If producing Inkjet proofs, Pantone colors must be simulated on proofs and must be 

proofed separately on a digital color content, overlay, or inkjet proof.

***Digital color content proof shall be used to represent spot varnish. 

4 set(s) of digital color content proofs. Direct to plate must be used to produce the final product with a minimum 

resolution of 2400 x 2400 dpi. 

Proofs must be created using the same Raster Image Processor (RIP) that will be used to produce the product. 

Proofs shall be collated with all elements in proper position (not pasted up), imaged face and back, trimmed and 

folded to the finished size of the product, as applicable. 

***Stock samples 5 sets.

At the same time as submission of the proofs, submit a minimum of 2”, 8-1/2 x 11 blank sheets to each proof 

addressee of the actual paper to be used in the production of the contract requirements. Each sample must be of 

the kind and quality required by the specifications. The Government will rely on the samples only as a reference 

to the general appearance of the stock that will be provided by the contractor in conformance to the specifications. 

The Government assumes no contractual obligation to perform any inspection and test for the benefit of the 

contractor. The Government's failure to inspect and accept or reject the paper samples shall not relieve the 
604-908 Page 4 of 9

contractor from responsibility, nor impose liability on the Government, for nonconforming paper. Stock samples 

must be approved by agency prior to printing.

STOCK APPROVAL NOTE: Stock samples must be sent to all specified proof addressees for approval PRIOR to 

any contractor stock procurement or use. The customer will not be held financially responsible for any stock 

procurement for this job that was not previously approved by the customer.

***Contractor to submit ink draw downs on actual production stock of Pantone color(s) used to produce the 

product. Half of drawdown must show varnish. Send to all specified proof addressees for approval PRIOR to any 

contractor procurement or use.

Proofs are due on/or before May 21, 2019 and will be held 5 working days. Proofs to be delivered to 4 

destinations. See below:

1. Two sets of proofs for each version (High Resolution proof set, Digital Content proof set, ink drawdowns for 

each pantone for each color version and stock samples), along with furnished materials directly to: Wunderman 

Thompson, Attn: Jackie McGowan, 466 Lexington Ave., New York, NY 10017, (212) 210-7806, M/F: DIRECT 

MAIL PROOFS.

Plus for all versions contractor to submit two "Press Quality" PDF "soft" proof (for content only) using the same 

Raster Image Processor (RIP) that will be used to produce the final printed product. PDF proof will be evaluated 

for text flow, image position, and color breaks. Proof will not be used for color match. Proofs must have all 

elements in proper position, trimmed, and constructed to the finished size specified. Email to: 

Jackie.mcgowan@jwt.com

2. One set of proofs for each version one (1) set of proofs (High Resolution proof set, Digital Content proof set, 

ink drawdowns for each pantone for each color version and stock samples), directly to: MARINE CORPS 

RECRUITING COMMAND, Attn: CAPT Molly Smith, Advertising Section, 2nd Floor, 3280 Russell Road, 

Quantico, VA 22134-5103, (703)784-9433, M/F: DIRECT MAIL PROOFS.

3. One set of proofs for each version one (1) set of proofs (High Resolution proof set, Digital Content proof set, 

ink drawdowns for each pantone for each color version and stock samples), directly to: JWT, Attn: Ms. Katie 

Garcia, 3630 Peachtree Road NE, Suite 1200, Atlanta, GA 30326.

4. One set of proofs for each version one (1) set of high resolution proofs set, ink drawdowns for each pantone 

for each color version and stock samples directly to: Melita Webb, US Government Publishing Office, 928 

Jaymor Rd., Suite A-190, Southampton, PA 18966, MF: Proofs J604-908.

PROOFING REQUIREMENTS: All of the requirements specified above must be met by the contractor. Failure 

to comply could cause the Government to return the proofs immediately for remedy. No additional time beyond 

the original production schedule established in these specifications will be allowed for fulfillment of proofing 

requirements.

NOTE: ALL PROOFS AND PAPER SAMPLES MUST BE SIGNED BY A REPRESENTATIVE OF YOUR 

COMPANY AND IDENTIFIED WITH THE COMPANY NAME.

REVISED PROOFS: The Government considers the proof to be the standard for the finished publication when 

approved for production. Contractors must strive for the best possible proof to insure approval. If, in the opinion 

of the Government Publishing Office, proof errors are significant, or if reproduction color and contrast vary from 

original significantly, submission of revised proofs will be required at contractor expense. No additional time 

beyond the original production schedule established will be given.

*** A possible second round of proofs may be required and should be considered and included in cost estimate 

when bidding on project/schedule.
604-908 Page 5 of 9

***Must be printed on a press capable of printing six colors (six printing units) plus aqueous coating in a single 

pass.

***Pantone colors cannot be build out of 4/c process, must be run as spot 5th and 6th colors.

***All PMS color must be shown in proofs as close as possible to the actual color. 

***This is a reprint and all components MUST match to the previously printed pieces.

***FINAL FILES: Upon completion of the printing, printer need to provide two (2) labeled final digital 

download along with directory of what was actually printed. Returned/sent along with the GFM.

Brochure-4 page plus cover with extended panel.

VERSION A – Control – (Code: FSC19) – 1,090,000 

VERSION B – Universal Gender – (Code: FSG19) – 475,000

TRIM SIZE: Constructed size: 5-1/2 x 8

Outside Cover Spread: 16-3/8 x 8”

(3 panels: 5-1/2’; 5-1/2 and 5-3/8 BRC Fold in)

1 Inside Spread: (4 Text Pages) - Flat: 11 x 8”

STOCK: The specifications of all paper furnished must be in accordance with those listed herein or

listed for the corresponding JCP Code numbers in the “Government Paper Specification Standards No. 12” dated

March 2011.

Government Paper Specification Standards No. 12 – https://www.gpo.gov/docs/default-source/formsandstandards-files-for-vendors/vol_12.pdf?sfvrsn=2.

Text: Outside: Cover, JCP Code L50, White Matte Coated, basic weight 80lbs

 Inside: Text, JCP A240, White Matte Coated, basis weight 80lbs

PRINTING/INK: 4 color process, Pantone 296 (Blue) and Pantone 187 (Red), plus Matte Aqueous Coating

MARGINS: Per art full bleeds on all pages. Heavy ink coverage except for extend BRC cover.

BINDING: Score and trim 3 sides. Tuck fold extended cover inward 5-3/8” from the right trim edge. Collate 

cover, 4 text papers and bind with two saddle wire stitches on the 8” side.

WAFER SEALS: Affix 1-1/2” non-perforated clear wafer seals as position below. Wafer seals must be clear 

(match previous) with clean break for opening affixed evenly to edge of printing piece. 
604-908 Page 6 of 9

PACKING: Pack in separate cartons by code new corrugated solid fiberboard containers with minimum bursting 

strength of 275 p.s.i. Shipping containers not to exceed 45 lbs. when fully packed. Carton labels must show title, 

item/lot number and source codes (where applicable), form number and control number and must appear on the 

outside of the shipping cartons. GPO 905 carton labels must be followed. Bulk packaging must be stabilized to 

avoid bursting or shifting on truck(s) during the delivery process, of which, may cause damage and/or hamper the 

letterhouse process. Follow enclosed DataMail Receiving Guidelines.

Pallets are required for all destinations receiving 10 or more shipping containers. Failure to properly palletize 

may be cause for re-palletizing at contractor's expense.

LABELING AND MARKING: (Package and/or Container label): Reproduce shipping container label from 

furnished repro, fill in appropriate blanks and attach to shipping containers. Carton labels must show title, version

number and source codes (where applicable), form number and control number and must appear on the outside of 

the shipping cartons.

SCHEDULE

Furnished material will be available for pick up at the U.S. Government Publishing Office, 928 Jaymor Rd., Suite 

A-190, Southampton, PA 18966 on May 16, 2019.

DISTRIBUTION: Deliver f.o.b. destination as follows:

DISTRIBUTION: Prior to bulk shipment, deliver 200 TOTAL sample packages 100 of each version = 50 

SEALED and 50 NOT SEALED to arrive on/or before June 4, 2019: 

 

Ms. Jackie McGowan 

Wunderman Thompson

 466 Lexington Ave.

New York, NY 10017 

(212)-210-7806 

DISTRIBUTION: Deliver the balance of 1,565,000 total on/or before June 6, 2019:

DATA MAIL

240 Hartford Avenue

Newington, CT 06111

ATTN: Colleen Costin/Scott Stickles

(860)-666-0399

Follow supplied sample of GPO 905 white carton label.

RETURN OF GOVERNMENT FURNISHED MATERIAL: There are two (2) requirements. All materials 

and receipts must be returned via traceable means. See breakdown below:

1. Immediately upon completion of this job, all Government Furnished Materials, Film and 7 printed copies 

of each item and packing slips are to be returned no later than June 29, 2019 to Ms. Jackie McGowan, 

Wunderman Thompson, New York, NY, 10017. Follow supplied sample of GPO 905 white carton label. 

NOTE: upon completion of this order, if there were any changes, or if there were no changes to the 

furnished files, the contractor MUST furnish final production native files (digital deliverables) along with 

the furnished material. The digital deliverables MUST be an exact representation (reflecting any such 

changes as "AAs" retouching, etc., that were performed on the files prior to printing the end product), and 

MUST be returned/sent on the same type media or storage as was originally furnished. Any other media 

type than those furnished are unacceptable, unless specified otherwise by the Government. Both the 

original furnished files, and the digital deliverables (the final digital download mechanical of the actual 

printed product; these electronic files are to be stored/filed for Agency records) MUST be returned/sent 

along with the GFM.
604-908 Page 7 of 9

2. Immediately upon completion and shipping of the above materials, return 3 printed copies of each version, to 

DAPS Quantico, 1001 Barnett Ave., Quantico, VA 22134, Attn: Curtis Cox.

COMPLIANCE REPORTING: Contractors are to report information regarding each order for compliance 

reporting purposes and include date(s) of completion, in accordance with the contract requirements by via email at 

infophiladelphia@gpo.gov or via telephone at (215)364-6465. Personnel receiving the fax will be unable to 

respond to questions of a technical nature.

QUALITY ASSURANCE LEVELS AND STANDARDS: The following levels and standards shall apply to 

these specifications:

Product Quality Levels: 

 (a) Printing Attributes -- Level 1

 (b) Finishing Attributes -- Level 1

 (c) Exceptions: None

Inspection Levels (from ANSI/ASQC Z1.4):

 (a) Non-destructive Tests - General Inspection Level 1.

 (b) Destructive Tests - Special Inspection Level S-2.

Specified Standards: The specified standards for the attributes requiring them shall be:

 Attribute Specified Standard

P-7. Type Quality and Uniformity O.K. Press Sheets

P-8. Halftone Match (Single and Double Impression) O.K. Press Sheets

P-9. Solid and Screen Tint Color Match O.K. Press Sheets

P-10. Process Color Match O.K. Press Sheets

Special Instructions: In the event that inspection of press sheets is waived by the Government, the following 

listed alternate standards (in order of precedence) shall become the Specified Standards:

P-7. Government furnished electronic media and approved proofs 

P-8. Government furnished electronic media and approved proofs 

P-9. Approved proofs

P-10. Approved proofs

QUALITY ASSURANCE RANDOM COPIES: 50 Samples of Each Version. The contractor is required to 

submit quality assurance random copies to test for compliance against specifications. The contractor must divide 

the entire order into 50 equal sublots for each Item and select a copy from a different general area of each 

sublot. The contractor will be required to execute a statement furnished by GPO certifying that copies were 

selected as directed. A copy of the purchase order/specifications must be included.

Business Reply Mail labels will be furnished for mailing the quality assurance random copies (***NOTE: to be 

mailed to WASHINGTON, DC). The copies are to be mailed at the same time as the first scheduled shipment. 

A U.S. Postal Service approved Certificate of Mailing, identified by Jacket and Purchase Order number must be 

furnished with billing.

PREAWARD SURVEY: In order to determine the responsibility of the prime contractor or any subcontractor, 

the Government reserves the right to conduct an on-site pre-award survey at the contractor's/subcontractor's 

facility or to require other evidence of technical, production, managerial, financial, and similar abilities to 

perform, prior to the award of a contract. As part of the financial determination, the contractor in line for award 

may be required to provide one or more of the following financial documents:

1) Most recent profit and loss statement

2) Most recent balance sheet

3) Statement of cash flows

4) Current official bank statement
604-908 Page 8 of 9

5) Current lines of credit (with amounts available)

6) Letter of commitment from paper supplier(s)

7) Letter of commitment from any subcontractor

The documents will be reviewed to validate that adequate financial resources are available to perform the contract 

requirements. Documents submitted will be kept confidential, and used only for the determination of 

responsibility by the Government. Failure to provide the requested information in the time specified by the 

Government may result in the Contracting Officer not having adequate information to reach an affirmative 

determination of responsibility.

PAYMENT: Submitting invoices for payment via the GPO fax gateway (if no samples are required) utilizing the 

GPO barcode coversheet program application is the most efficient method of invoicing. Instruction for using this 

method can be found at the following web address: 

http://winapps.access.gpo.gov/fms/vouchers/barcode/instructions.html. 

Invoices may also be mailed to: U.S. Government Publishing Office, Office of Financial Management, Attn: 

Comptroller, Stop: FMCE, Washington, DC 20401. 

For more information about the billing process refer to the General Information of the Office of Finance web page 

located at https://www.gpo.gov/how-to-work-with-us/vendors/how-to-get-paid.

OFFERS: Offers must include the cost of all materials and operations for each item listed in accordance with 

these specifications. 

BID SUBMISSION: Submit bid in pre-addressed envelope furnished with solicitation or send to: U.S. 

Government Publishing Office, 928 Jaymor Road, Suite A-190, Southampton, PA 18966. Facsimile bids in 

response to this solicitation are permitted. Facsimile bids may be submitted directly to Fax No. 215-364-6476.

The jacket numbers and bid opening date must be specified with the bid. Refer to Facsimile Bids in Solicitation 

Provisions of GPO Contract Terms, GPO Publication 310.2, as revised January 2018. 
604-908 Page 9 of 9

SHIPMENT(S): Shipments will be made from: City _____________________, State_______________

The city(ies) indicated above will be used for evaluation of transportation charges when shipment f.o.b. 

contractor’s city is specified. If no shipping point is indicated above, it will be deemed that the bidder has 

selected the city and state shown below in the address block, and the bid will be evaluated and the contract 

awarded on that basis. If shipment is not made from evaluation point, the contractor will be responsible for any 

additional shipping costs incurred.

JACKET NO: _______________________

Bid Price $ _____________________ Additional ________________ Rate __________________

DISCOUNTS: Discounts are offered for payment as follows: __________ Percent, _________calendar days. 

See Article 12 “Discounts” of Solicitation Provisions in GPO Contract Terms (Publication 310.2).

BID ACCEPTANCE PERIOD: In compliance with the above, the undersigned agree, if this bid is accepted 

within____________ calendar days (60 calendar days unless a different period is inserted by the bidder) from the 

date for receipt of bids, to furnish the specified items at the price set opposite each item, delivered at the 

designated points(s), in exact accordance with specifications.

NOTE: Failure to provide a 60-day bid acceptance period may result in expiration of the bid prior to award.

AMENDMENT(S): Bidder hereby acknowledges amendment(s) number(ed) ______________________

BIDDER’S NAME AND SIGNATURE: Unless specific written exception is taken, the bidder, by signing and 

submitting a bid, agrees with and accepts responsibility for all certifications and representations as required by the 

solicitation and GPO Contract Terms - Publication 310.2. 

Failure to sign the signature block below may result in the bid being declared non-responsive.

_______________________________________________ ________________________________

 (Company Name) (GPO Contractor’s Code)

_____________________________________________________________________________________

(Street Address, City, State and Zip Code)

______________________________________________ _________________________________

 (Printed Name and Title) (Telephone number)

______________________________________________ _________________________________

(Signature) (Date)

______________________________________________ ________________________________

(E-Mail) (Facsimile Number)

*******************************************************************************************

THIS SECTION FOR GPO USE ONLY

Certified by: __________ Date: ___________ Contracting Officer: __________ Date: ___________

 (Initials) (Initials)

********************************************************************************