Certification of contract

Fax or Email form to: Donna Smith, 850-414-6122 or [e-mail]
CALENDAR QUARTER: Check One

 Quarterly Period Ending March 31st	 Quarterly Period Ending June 30th
 Quarterly Period Ending September 30th	 Quarterly Period Ending December 31st

ENTITY	TOTAL DOLLARS
STATE AGENCIES: Report dollar amount sold to all State Agencies. List each Agency separately.	$      
POLITICAL SUBDIVISIONS: Report dollar amount sold to other Political Subdivisions [including but not limited to, Counties, Cities, Schools, Universities, Colleges and Utilities]. List each entity separately.	$      
GRAND TOTAL:	$      

Under penalties of perjury, I declare that this is a true and accurate report of all sales due under the terms and conditions of this state term contract for the specified quarterly reporting period.
AUTHORIZED TYPED SIGNATURE:      


     

AUTHORIZED ELECTRONIC SIGNATURE:

Notes:

1) A quarterly report is required even if there are no sales for the specified quarter; please enter zero dollars where applicable.

2) This form is for the reporting of quarterly sales only. It is not related to reporting and payment of vendor transaction fees.

3) To enter electronic signature, click text box, click “Insert” (on tool bar), select “picture”, and select picture type to paste or enter signature.

4) For information concerning the use of this form, please contact the Contract Administrator named above.

(Rev. 3/05/09)

CONTRACT
This Contract, effective the last date signed below, is by and between the State of Florida, Department of Management Services (“Department”), an agency of the State of Florida with offices at 4050 Esplanade Way, Tallahassee, Florida 32399-0950, and the entity identified below as Contractor (“Contractor”).The Contractor responded to the Department’s Request for Proposal No. 10-475-000-J for Medical and Dental Supplies. The Department has determined to accept the Contractor’s response and to enter into this Contract in accordance with the terms and conditions of the solicitation.

Accordingly, and in consideration of the mutual promises contained in the Contract documents, the Department and the Contractor do hereby enter into this Contract, which is a state term contract authorized by section 287.042(2)(a) of the Florida Statutes (2001). The term of the Contract is 36 months from the effective date. The Contract consists of the following documents, which, in case of conflict, shall have priority in the order listed, and which are hereby incorporated as if fully set forth:

• 
  Any written amendments to the Contract
  
• 
  Technical Specifications
  
• 
  Special Contract Conditions
  
• 
  General Contract Conditions (PUR 1000)
  
• 
  Special Instructions to Respondents
  
• 
  General Instructions to Respondents (PUR 1001)
  
• 
  This document
  
• 
  Any Purchase Order under the Contract
  
• 
  Contractor’s response
  

___________________________________________

State of Florida, Date

Department of Management Services

By: Linda H. South, Secretary

Contractor Name: (Seal)

Street Address or P.O. Box:

City, State, Zip:

_______________________________________________

By: Date

Its (Title): ­­­_________________________________
Approved as to form and legality by the General Counsel’s Office

______________________________________

Print name: __________________________ Date: ____________________