HomeMy WebLinkAbout063353 - General - Contract - Performance Health Supply, LLC dba Medco SupplyCITY OF FORT WORTH
COOPERATIVE PURCHASE AGREEMENT
This Cooperative Purchase Agreement (“Agreement”) is entered into by Performance Health
Supply, LLC dba Medco Supply (“Vendor”), an Illinois Limited Liability Company, and the City of
Fort Worth (“City”), a Texas home-rule municipality, individually referred to as “party” and
collectively as the “parties”.
The Cooperative Purchase Agreement includes the following documents which shall be construed in the
order of precedence in which they are listed:
1. This Cooperative Purchase Agreement;
2. Exhibit A –Seller’s Quote;
3. Exhibit B – Cooperative Agency Contract BuyBoard 704-23; and
4. Exhibit C – Conflict of Interest Questionnaire.
Exhibits A, B, and C, which are attached hereto and incorporated herein, are made a part of this
Agreement for all purposes. Vendor agrees to provide City with the services and goods included in
Exhibit A pursuant to the terms and conditions of this Cooperative Purchase Agreement, including all
exhibits thereto. If any provisions of the attached Exhibits conflict with the terms herein, are prohibited
by applicable law, conflict with any applicable rule, regulation or ordinance of City, the terms in this
Cooperative Purchase Agreement shall control.
City shall pay Vendor in accordance with the payment terms in Exhibit A and in accordance with
the provisions of this Agreement. Total payment made under this Agreement by City shall not exceed
Fifty Thousand Dollars ($50,000.00) annually. Vendor shall not provide any additional items or
services or bill for expenses incurred for City not specified by this Agreement unless City requests and
approves in writing the additional costs for such services. City shall not be liable for any additional
expenses of Vendor not specified by this Agreement unless City first approves such expenses in writing.
The Parties will engage in multiple transactions to purchase goods and/or services under this
Agreement. For each purchase made pursuant to this Agreement, Vendor must supply a quote for the
subject goods and/or services and the quote must conform with the then-current pricing under the
underlying cooperative agreement. If the City accepts the quote and places an order for the goods and/or
services, that quote shall be considered as an addendum to this agreement but is not required to be filed
in the City records. The Parties will maintain all quotes for the 3- year Audit period included herein.
The term of this Agreement is effective beginning on the date signed by the Assistant City
Manager ("Effective Date") and expires on May 31, 2026.City or Vendor may terminate this Agreement
at any time and for any reason by providing the other party with at least 7 days' written notice of
termination.
Vendor agrees that City shall, until the expiration of three (3) years after final payment under this
Agreement, or the final conclusion of any audit commenced during the said three years, have access to
and the right to examine at reasonable times any directly pertinent books, documents, papers and records,
including, but not limited to, all electronic records, of Vendor involving transactions relating to this
Agreement at no additional cost to City. Vendor agrees that City shall have access during normal
working hours to all necessary Vendor facilities and shall be provided adequate and appropriate work
space in order to conduct audits in compliance with the provisions of this section. City shall give Vendor
reasonable advance notice of intended audits.
Notices required pursuant to the provisions of this Agreement shall be conclusively determined
to have been delivered when (1) hand-delivered to the other party, its agents, employees, servants or
representatives or (2) received by the other party by United States Mail, registered, return receipt
requested, addressed as follows:
To CITY:
City of Fort Worth
Attn: Assistant City Manager
100 Fort Worth Trail
Fort Worth, TX 76102
With copy to Fort Worth City Attorney’s Office at the
same address
To VENDOR:
Performance Health Supply, LLC dba Medco
Supply Company
Attn: Kristen Howell
25 Northpointe Parkway, Suite 25
Amherst, NY 14228
Email: Medcosalessupport@medcosupply.com
City is a government entity under the laws of the State of Texas and all documents held or
maintained by City are subject to disclosure under the Texas Public Information Act. To the extent the
Agreement requires that City maintain records in violation of the Act, City hereby objects to such
provisions and such provisions are hereby deleted from the Agreement and shall have no force or effect.
In the event there is a request for information marked Confidential or Proprietary, City shall promptly
notify Vendor. It will be the responsibility of Vendor to submit reasons objecting to disclosure. A
determination on whether such reasons are sufficient will not be decided by City, but by the Office of
the Attorney General of the State of Texas or by a court of competent jurisdiction.
The Agreement and the rights and obligations of the parties hereto shall be governed by, and
construed in accordance with the laws of the United States and state of Texas, exclusive of conflicts of
law provisions. Venue for any suit brought under the Agreement shall be in a court of competent
jurisdiction in Tarrant County, Texas. To the extent the Agreement is required to be governed by any
state law other than Texas or venue in Tarrant County, City objects to such terms and any such terms are
hereby deleted from the Agreement and shall have no force or effect.
Nothing herein constitutes a waiver of City’s sovereign immunity. To the extent the Agreement
requires City to waive its rights or immunities as a government entity; such provisions are hereby deleted
and shall have no force or effect.
To the extent the Agreement, in any way, limits the liability of Vendor or requires City to
indemnify or hold Vendor or any third party harmless from damages of any kind or character, City
objects to these terms and any such terms are hereby deleted from the Agreement and shall have no force
or effect.
If Vendor has fewer than 10 employees or this Agreement is for less than $100,000, this section
does not apply. Vendor acknowledges that in accordance with Chapter 2271 of the Texas Government
Code, the City is prohibited from entering into a contract with a company for goods or services unless
the contract contains a written verification from the company that it: (1) does not boycott Israel; and (2)
will not boycott Israel during the term of the contract. The terms “boycott Israel” and “company” has
the meanings ascribed to those terms in Chapter 2271 of the Texas Government Code. By signing this
Agreement, Vendor certifies that Vendor’s signature provides written verification to the City that
Vendor: (1) does not boycott Israel; and (2) will not boycott Israel during the term of the Agreement.
If Vendor has fewer than 10 employees or this Agreement is for less than $100,000, this section
does not apply. Vendor acknowledges that in accordance with Chapter 2276 of the Texas Government
Code, the City is prohibited from entering into a contract for goods or services that has a value of
$100,000 or more that is to be paid wholly or partly from public funds of the City with a company with
10 or more full-time employees unless the contract contains a written verification from the Vendor that
it: (1) does not boycott energy companies; and (2) will not boycott energy companies during the term of
this Agreement. To the extent that Chapter 2276 of the Government Code is applicable to this
Agreement, by signing this Agreement, Vendor certifies that Vendor’s signature provides written
verification to the City that Vendor: (1) does not boycott energy companies; and (2) will not boycott
energy companies during the term of this Agreement.
If Vendor has fewer than 10 employees or this Agreement is for less than $100,000, this section
does not apply. Vendor acknowledges that except as otherwise provided by Chapter 2274 of the Texas
Government Code, the City is prohibited from entering into a contract for goods or services that has a
value of $100,000 or more that is to be paid wholly or partly from public funds of the City with a
company with 10 or more full-time employees unless the contract contains a written verification from
the Vendor that it: (1) does not have a practice, policy, guidance, or directive that discriminates against
a firearm entity or firearm trade association; and (2) will not discriminate during the term of the contract
against a firearm entity or firearm trade association. To the extent that Chapter 2274 of the Government
Code is applicable to this Agreement, by signing this Agreement, Vendor certifies that Vendor’s
signature provides written verification to the City that Vendor: (1) does not have a practice, policy,
guidance, or directive that discriminates against a firearm entity or firearm trade association; and (2) will
not discriminate against a firearm entity or firearm trade association during the term of this Agreement.
(signature page follows)
(remainder of this page intentionally left blank)
The undersigned represents and warrants that he or she has the power and authority to execute
this Agreement and bind the respective party.
CITY OF FORT WORTH:
4 4 By:
Name: William Johnson
Title: Assistant City Manager
Date: 12/11/2025
APPROVAL
O rl/W
By.
Name: Raymond Hill
Title: Interim Fire Chief
CONTRACT COMPLIANCE MANAGER:
By signing I acknowledge that I am the person
responsible for the monitoring and
administration of this contract, including
ensuring all performance and reporting
requirements.
By: AW
Name: Brenda Ray
Title: Purchasing Manager
APPROVED AS TO FORM
AND LEGALITY:
Name: Amama Muhammad
•�h��� � a an9 Title: Assistant City Attorney
By:
Name: Jannette Goodall o_e`*°� CONTRACT AUTHORIZATION:
Title: City Secretary °¢o®*j M&C: N/A
aeaay Date Approved: N/A
1295 Form: N/A
\LIIC1111131
Performance Health Supply, LLC dba Medco Supply
By: 016 0;19"Oks
Name: Allison Brooks
Title: South Central Inside Sales Coordinator
Date: 11/14/25
OFFICIAL RECORD
CITY SECRETARY
FT. WORTH, TX
EXHIBIT A
Quote
�.�
mate # Esti: ESTMD3176050
.3�MEDCOe
SPOA 1 i �, �� 1,6 .I. 'SCHOOL FAMAIV
Customer RFP#: Buyboard 704-23
10/28/2025
asune Surg calsupplyservice
FaiST AIO b S1F6TY
Performance Health Supply, LLC
d/b/a Medco Supply Company
3333 Finley Road, Suite 575
Downers Grove, IL 60515
United States
Ship To Bill To Total:
Brian Newman City of Fort Worth Fire Department
City of Fort Worth Fire Department 509 W Felix St $8,675.70
509 W Felix St Fort Worth, TX 76115-3405
Fort Worth, TX 76115-3405 US
US
Custwner Number Expires
Sales Rep sales Rep Email
Quote Prepared By
Order source
200113625 11127=5
KMSTEN HOWELL knsteu.hood1@medcosupplvcom
Knsten.Hewell@medcosupply.com
Phone
Lift# Alternate Number
Item
Rate UOM
Quantity Amount
1
7021995
$1,349.00 HA
2 $2,698.00
Normatec 3 Full Body Pkg Sod
IC1 ,ndudes dewce, hose, powersupply, boots.
arm attedunerds and ran attawmad. In.aroek-
shpso,rtwhenw nsf.
2
7021288
$5,48663 PA
1 $5,486.0
HIVAMATPersonel
Pomona)itchdes: see notes In stockwhgs
our when ordered.
Subtotal
$8,184.63
Shipping and Handing Cost
$491.07
Tax Total
$000
Total
$8,675,70
Quote Notes:
Hivamat Personal includes: Applicator handhold (1), Charging device (1), Connection cable Deep Oscillation (2), Connection
cable grey for adhesive electrodes (1), Operating instructions (1), Oscillator head 0 5 cm (2), Oscillator head 0 9.5 cm (2),
Therapy card (1), Titanium neutral element(1), Transportation bag (1), Box of vinyl gloves (1), Sample self-adhesive 3.2 cm
snap electrode (1 pk. of 4).
Web sne. hnpx�iw.w.medwemletica.wm
customer Service b: 80MM-3326
small'. mMcoaelessuppotl@medcosupply.wm
1
AY•
%oard
•
April 17, 2023
Sent Via Email: Medcosalessupport@medcosupply.com
Stephen Weiss
Medco Supply Company
21800 Torch Parkway, Suite 800
Warrenvdle, IL 60555
Welcome to BuyBoardl
P.O. Box 400, Austin, Texas 78767
800.695.2919 • infa®buyboard.cem •buyboard.com
Re: Ndh09 Of The Local Govemment Vurchasfng Co0pe2dtive ContnadAw"; Proposal Invitation No. 704-
23, First Aid, Emergency Medical, and Athletic Trainer Supplies and Equipment
Congratulations, The Local Government Purchasing Cooperative (Cooperative) has awarded your company
a BuyBoard contract based on the above -referenced Proposal Invitation. The contract is effective for an
initial one-year term of June 1, 2023, through May 31, 2024, and may be subject to two possible one-year
renewals. Please refer to the Proposal Invitation for the contract documents, including the General Terns
and Conditions of the Contract.
To review the items your company has been awarded, please review Proposal Tabulation No. 704-23 at:
www.buyboard.com/vendor. Only items marked as awarded to your company are included in this contract
award, and only tbose awarded items may be sold through the BuyBoard contract. All sales must comply
with the contract terms and must be at or below the awarded pricing as set forth in the General Terms and
Conditions.
The contract will be posted on the BuyBoard website as an online electronic catalog(s). You are reminded
that, in accordance with the General Terms and Conditions, all purchase orders must be
processed through the BuyBoard. Except as expressly authorized in writing by the Cooperative's
administrator, you are not authorized to process a purchase order received directly from a Cooperative
member that has not been processed through the BuyBoard or provided to the Cooperative. If you receive
a purchase order directly from a Cooperative member that you have reason to believe has not been received
by the Cooperative or processed through the BuyBoard, you must promptly forward a copy of the purchase
order by email to info@buyboard.com.
A list of Cooperative members is available on the buyboard.com website. The BuyBoard vendor relations
staff will be contacting you to assist with the resources available and to provide any support you may need
as an awarded BuyBoard vendor.
On behalf of the Cooperative, we appreciate your interest in the Cooperative and we are looking forward
to your participation in the program. If you have any questions, feel free contact me at 800-695-2919.
Sincerely,
r l° N
Ava Benford, Cooperative Procurement Manager
Texas Association of School Boards, Inc.,
Administrator for The Local Government Purchasing Cooperative
02 of 2021
Board®
April 17, 2023
Sent Via Email: Medcosalessupport@medmsupply.com
Stephen Weiss
Medco Supply Company
21800 Torch Parkway, Suite 800
Warrenville, IL 60555
Welcome to BuyBoard!
Re: I WCL Of Natfonai R/rcnasirlg COOMrative AWald- Proposal Invitabon No. 704-23, First Aid, Emergency Medical,
and Athletic Trainer Supplies and Equipment
Congratulations, The National Purchasing Cooperative (National Cooperative) has awarded your company a BuyBoard@
contract based on the above -referenced Proposal Invitation. The contract is effective for an mibal one-year term of June 1,
2023, through May 31, 2024, and may be subject to two possible one-year renewals. Please refer to the Proposal
Invitation for the contract documents, including the National Purchasing Cooperative Vendor Award Agreement and General
Terms and Conditions of the Contract.
To review the items your company has been awarded, please review Proposal Tabulation No. 704-23 at
www.buvboard.comNendoc Only Items marked as awarded to your company are included in this contract award, and only
those awarded items may be sold through the BuyBoard contract. All sales must comply with the contract terms and must
be at or below the awarded pricing as set forth in the General Terms and Conditions.
The contract will be posted on the BuyBoard websne as an online electronic catalog(s). You are reminded that, in
accordance with the General Terms and Conditions, all purchase orders from National Cooperative members
must be processed through the BuyBoard. Except as expressly authorized in writing by the Cooperative's administrator,
you are not authorized to process a purchase order received directly from a National Cooperative member that has not
been processed through the BuyBoard or provided to the Cooperative. If you receive a purchase order directly from a
National Cooperative member that you have reason to believe has not been received by the National Cooperative or
processed through the BuyBoard, you must promptly forward a copy of the purchase order by e-mail to
info@buyboard.com
A list of National Cooperative members is available on the buyboard.com website. The BuyBoard vendor relations staff will
be contacting you to assist with resources available and provide any support you may need as an awarded BuyBoard
vendor.
On behalf of the National Cooperative, we are looking forward to your participation in the program. If you have any questions,
feel free to contact me at 800-695-2919.
1'
Ava Benford, Cooperative Procurement Marager
Texas Association of School Boards, Inc.,
Procurement Administrator for the National Purchasing Cooperative
v 02012021
P.O. 6ex40p Austin, Texas fU161-0400
800,695.2919 • buyboar0. can
PT Boarda
Fua:xpavrm cuaPrxann
12007 Research Boulevard • Austin, Texas 78759-2439 • PH: 800-695-2919 • buvboard.com
PROPOSER'S ACCEPTANCE AND AGREEMENT
P al Invitation Name: First Aid, Emergency Proposal Due DateMnina Date and Time:
M cal, and Athletic Trainer Supplies and January 26, 2023, at 00 PM
Equipment
Proposal Invitation Number: 704-23
Contract'renn: June 1, 2023, through May 31,
2024, with two possible one-year renewals.
Location of Prop 1007mo:
Texas Association 0 o Boards, Inc.
BuyBoard Department
12007 Research Blvd.
Austin, TX 78759
Anticioated C000erative Board Meeting Date:
April 2023
By signature below, the undersigned acknowledges and agrees that you are authorized to submit this
Proposal, including making all acknowledgements, consents, and certifications herein, on behalf of proposer
and, to the best ofyour knowledge, the information provided is true, accurate, and complete.
Pe "anm AMth Supply LLC . DBA Meam Supply Campa
Name of Proposing Company
28100 Torch Parkway, Suite 800
Street Address
Warrenville, IL 60555
City, State, ZJp
800-556-3326
Telephone Number of Authorized Company Official
800-222-1934
Fax Number of Authorized Company Official
1 /23/2023
Date
5' (()azce.
Signature of Authorized Company Official
Stephen Weiss
Printed Name of Authorized Company Official
Sales Support Coordinator
Position or Title of Authorized Company Official
36-4391091
Federal ID Number
Page 10 of 71
PmXWrams COmm�vW111@1
Board-
PURCNASJN9 CCOPERATWE
MW Research Boulevard I Austin, i e;wa /J/59-Z439 ' PH: M-WS-2919 ' buybuard.curn
PWPOSAL FUkMS PAkT 1; CUMPLIANCE Fukms
Prupusei must review and complete all forms in this Proposal Fuims Part 1:
■ Wupusdl ALknuwledgemerits
■ Felony CunviLtiun DiSdUSUVe
■ kesident/Nuni-esident CeitifiLdticin
■ Debai-ment CeitifiLdtiun
■ Vendui- Empluyment Celtiftdtiun
• Nu Boycott Vefiftdti101n
■ Nu Excluded Nation ui, Fui-eignfen-udst Oi'gdnizdtiUn Celtiftdtiun
■ HiStUdLdlly Undei-utilized Business Ceitiftatiun
■ AlLknuwledgement of BuyBuai d T UlLhnilLdl Requirements
• CunAVUWW-Related Goods and SelViLes Affirmation
■ Deviatiun and CUMplidnlLe
■ Vendui- Cunsent fui Name Bi and Use
■ Cunfidential/PiupOetaq infuimatiun
■ EDGAR Vendut Ceitiftatiun
■ CUMplidnlLe Fui'ms Signature Page
An authorized off Proposer must Initial In the bottom right corner of each oaqewhere indicated
and complel:_ —,,u simgii the Compliance Forms Signature Page. Proposer's taiiure to Cully* complete, initial, and
sign turms may resuit in your Proposai being rejected as non -responsive.
PROPOSAL AcKNOWLEDGEMENTS
The pi,upusing ILUMpany Cyuu" ui, "yuur") hereby dLknuwledges and 'agrees as fulluws:
1. Yuu have carefully examined and understand all infui matiun and dULUMentatiUln aSSULiated with this Piupusal invitation,
including the instruLtiuns to Pi'upusei's, General infui'matiun, General Terms and Cunditiuns, attaLhments/tuims,
appendices, item SpedtiLdtiuns, and line items (LUlleLtiVely "Requh'ements"),
2. By yuui, tespunse ("Kupusal'r) to this Ptupusal invitatiun, yuu propose tu supply the pi uduLts ut services submitted at
the pricing quoted in yuur Prupusal and in strict LUMplia"Le with the Requirements, unless specific deviations ur
eXlLeptiuns are noted in the Prupusal,
F
3. By YUUV PWPUSal, YUU aLk"uwledge and Leltify all items set fuith in the General Tei'ms and Cunditiuns, SeLtiun 8.12
(CeltiftatiUnS), including all nun-WlUsiun LeitifilLatiuns and Leitiftatiuns regarding legal, ethical, and uthei, matters set
fuith therein.
4. Any and all deviations and eXLeptiU"S to the Requitements have been noted in yulat Kupusal un the required Turin and
nu utheis will be ddimed.
-
initial: SHW
Page i I Ut A
Proposal Forrus LUMM/Sy-LS v.08.11.2021
PT Boarda
Fuxexpavrm cucPrxanvr
12007 Research Boulevard • Austin, Texas 78759-2439 • PH: 800-695-2919 • buvboard.com
5. If the Cooperative accepts any part of your Proposal and awards you a Contract, you will furnish all awarded products or
services at the pricing quoted and in strict compliance with the Requirements (unless specific deviations or exceptions
are noted on the required form and accepted by the Cooperative), including without limitation the Requirements related
to:
a. conducting business with Cooperative members, including offering pricing to members that is the best you offer
compared to similarly situated customers in similar circumstances;
b. payment of a service fee in the amount specified and as provided for in this Proposal Invitation;
c. the possible award of a piggy -back contract by the National Purchasing Cooperative or nonprofit entity, in which
event you will offer the awarded products and services in accordance with the Requirements; and
d. submitting price sheets orcatalogs in the proper format as required by the Cooperative as a prerequisite to activation
of your Contract;
6. You have clearly Identified on the included form any information In your Proposal that you believe to be confidential or
proprietary or that you do not consider to be public information subject to public disclosure under the Texas Public
Information Act or similar public information law;
7. The individual submitting this Proposal is duly authorized to enter into the contractual relationship represented by this
Proposal Invitation on your behalf and bind you to the Requirements, and such individual (and any Individual signing a
form or Proposal document) is authorized and has the requisite knowledge to provide the information and make the
representations and certifications required in the Requirements;
B. You have carefully reviewed your Proposal, and certify that all information provided is true, complete, and accurate to
the best of your knowledge, and you authorize the Cooperative to take such action as it deems appropriate to verify such
Information; and
9. Any misstatement, falsification, or omission In your Proposal, whenever or however discovered, will be grounds for
disqualifying you from consideration for a contract award under this Proposal Invitation, termination of a contract award,
or any other remedy or action provided for in the General Terms and Conditions or by law.
FELONY CONVICTION DISCLOSURE
Subsection (a) of Section 44.034 of the Texas Education Code (Notification of Criminal History of Contractor)
states: "A person or business entity that enters into a contract with a school district must give advance notice to the district
if the person or an owner or operator has been convicted of a felony. The notice must include a general description of the
conduct resulting in the conviction of a felony."
Section 44.034 further states in Subsection (b): "A school district may terminate a contract with a person or business
entity if the district determines that the person or business entity failed to give notice as required by Subsection (a) or
misrepresented the conduct resulting in the conviction. The district must compensate the person or business entity for
services performed before the termination of the contract.,
Please check (JA one of the followin
❑ My company is a publicly -held corporation. (Advance notice requirement does not apply to publicly -held corpurabon.)
❑W My company is not owned or operated by anyone who has been convicted of a felony.
❑ My company is owned/operated by the following individual(s) who has/have been convicted of a felony:
Name of Felon(s): N/A
Details of Conviction(s): N/A
Initial: SHW
Page 12 of 71
PNWWrom5C0MM�v W 11M1
PT Boarda
Fuxexpavrm cuePrxamr
12007 Research Boulevard • Austin, Texas 78759-2439 • PH: 800-695-2919 • buvboard.com
RESIDENT/NONRESIDENT CERTIFICATION
Chapter 2252, Subchapter A, of the Texas Government Code establishes certain requirements applicable to proposers who
are not Texas residents. Under the statute, a "resident" proposer is a person whose principal place of business is in Texas,
including a contractor whose ultimate parent company or majority owner has Its principal place of business in Texas. A
"nonresident" proposer is a person who is not a Texas resident. Please Indicate the status of your company as a "resident"
proposer or a "nonresident" proposer under these definitions.
Please oheok W) one of the followina:
❑ I certify that my company is a Resident Proposer.
❑K I certify that my company is a Nonresident Proposer.
If your company is a Nonresident Proposer, you must provide the following information for your resident state (the state in
which your company's principal place of business is located):
Performance Health Supply LLC , DBA Medco Supply Company
Company Name
Warrenville
City
28100 Torch Parkway, Suite 800
Address
IL 60555
State Zip Code
Does your resident state require a proposer whose principal place of business is in Texas to under -price proposers
whose resident state is the same as yours by a prescribed amount or percentage to receive a comparable contract?
❑ Yes 0 No
What is the prescribed amount or percentage? $ N/A a N/A o/o
DEBARMENT CERTIFICATION
By signature on the Compliance Forms Signature Page, I certify that neither my company nor an owner or principal of my
company has been debarred, suspended or otherwise made Ineligible for participation in Federal Assistance programs under
Fxecutive Order 12549, "Debarment and Suspension;' as described in the Federal Register and Rules and Regulations.
Neither my company nor an owner or principal of my company is currently listed on the government -wide exclusions in SAM,
debarred, suspended, or otherwise excluded by agencies or declared ineligible under any statutory or regulatory authority.
My company agrees to immediately notify the Cooperative and all Cooperative members with pending purchases or seeking
to purchase from my company if my company or an owner or principal is later listed on the government -wide exclusions in
SAM, or is debarred, suspended, or otherwise excluded by agencies or declared ineligible under any statutory or regulatory
authority.
VENDOR EMPLOYMENT CERTIFICATION
Section 44.031(b) of the Texas Education Code establishes certain criteria that a school district must consider when
determining to whom to award a contract. Among the criteria for certain contracts is whether the vendor or the vendor's
ultimate parent or majority owner (i) has its principal place of business in Texas; or (ii) employs at least 500 people in Texas.
If neither your company nor the ultimate parent company or majority owner has its principal place of business in Texas, does
your company, ultimate parent company, or majority owner employ at least 500 people in Texas?
Please check fJl one of the following:
❑ Yes 0 No
Page 13 of 71
Initial: SHW
PNppsai MSCOMM�Vffl11]@1
D:VBoard-
PURrhASJNG CCOPERATNE
12C W Research Buulevard ' Austin, l ec /J/!)9-A39 ' PH: 8UU-b95-2919 ' buybuard.culrn
No BOYCUTT'VER1FICATION
A Texas governmental entity may nut enter into a cuntrract with a value of $1UU,UUU ur mare that is tU be paid wholly ur
partly hum, public funds with a company (excluding a sole pruprietur°ship) that has 1U or more full-time employees fur goods
Ur services unless the contract contains a written verification frum, the company that it: (1) does nut buycutt Israel and wil I
nut buycutt Israel during the term Uf the contract (iEx. Guv'r CvuE Ch. 2271), (2) does not buycutt energy companies and
will nut buycutt energy companies during the term Uf the cuntract (iiEx. Guv'r CuuE Ch. 22/4 effective September 1, 2U21),
and (3) dues not have a practice, policy, guidance, ur directive that discriminates against a firearm entity Ur firearm trade
assuciatiun and will nut discriminate during the term, of the cuntract against a hiearm, entity Ur fireai m trade association (TEx.
Gov'i, CouE Ch. 22l4 effective September 1, 2U21). Accordingly, this certificdtiun form is included to the extent required by
law.
"Buycutt Israel" means refusing tU deal with, terminating business activities with, ur otherwise taking any actiun that is
intended tU penalize, inflict economic haim, un, ur limit cumml vial relations specifically with Israel, ui with a person of entity
doing business in Israel ui in an Israeli-cuntrulled territury, but dues not include an actiun made fur uidinaiy business
purpuses. i Ex. Guv r CouE §8U8.UU1(i).
"liuycUtt energy company" means, without an ui dindiy business puipuse, refusing to deal with, terminating business activities
with, ur utherwise taking any actiun that is intended to penalize, inflict economic harm Un, Ur limit commercial ielations with
a cUmpany because the cUmpany: (A) engages in the expluratiun, pi°oductiun, utilization, transpurtatiun, sale, ur
manufacturing of fussil fuel -based energy and dues nut cUmmit Ur pledge to meet envirunmental standards beyond applicable
federal and state law; ur (li) dues business with d cUmpany described by Pdidyldph (A). L` x. Gav`r CouE §8U9.UUi(1)
(effective September 1, 2U21).
"DiScrimindte against d firearm entity ur firearm trade assUcidtiUn" means, (A) with IUspect tU the entity ur dSSUcidtiUn, tU:
(i) refuse tU engage in the trade of any guudS or° Sei viceS with the entity Ur assuciatiun based solely un its status as a firearm
entity ur firearm trade assuciatiun; (ii) refrain from Cuntinuing an existing business relatiunship with the entity Ur dSSUCiatian
based solely un its status as a fit eat m entity ur firearm trade aSSUCiatiun; Ur (iiij terminate an existing business relatiunship
with the entity Ur dSSUciatiun based solely un its Status as a firearm entity ur firearm trade assuciatiun, and (8) dues nut
include: (i) the established pUlicieS Uf d merchant, retail seller, ur platfurm that restrict ur pruhibit the listing ur selling of
dmmunitiUn, firearms, Ur firearm acceSSuries; and (ii) d cUmpdny's refusal to engage in the trade Uf any guudS Ur Services,
decision to refrdin from continuing an existing business relatiunship, Ur decisiun to terminate an existing business relatiunship:
(dd) tU comply with federal, State, Ur lUcal law, policy, Ur regulatiuns ur a directive by a regulatury agency; ur (bb) fur any
traditiunal business reasun that is specific to the costumer urputential costumer and nut based Sulely un an entity's ur
assuciatiun's Status as a firearm entity ur firearm trade assuciatiun. "rEx. Guv'r CUuE §2274.UUi(3) (effective September 1,
2U21).
By Signature un the Compliance Furms Signature page, to the extent applicable, i certify and verify that Vendur dues nut
buryLutt Israel, boycott energy companies, ur discriminate against a firearm entity ur firearm trade association and will nut
do so during the term Uf any cuntract awarded under this Prupusal invitatiun, that this certification is true, cUmplete and
accurate, and that I am authurized by my cUmpany tU make this certificatiun.
initiall: JSHW
Page A ur A
Proposal Forrtu LUMM/SK:S v.08.11.2021
PT Boarda
Fuxexpavrm cucPrxanrr
12007 Research Boulevard • Austin, Texas 78759-2439 • PH: 800-695-2919 • buvboard.com
NO EXCLUDED NATION OR FOREIGN TERRORIST ORGANIZATION CERTIFICATION
Chapter 2252 of the Texas Government Code provides that a Texas governmental entity may not enter into a contract with
a company engaged in active business operations with Sudan, Iran, or a foreign terrorist organization — specifically, any
company identified on a list prepared and maintained by the Texas Comptroller under Texas Government Code §§806.051,
807.051, or 2252.153. (A company that the U.S. Government affirmatively declares to be excluded from its federal sanctions
regime relating to Sudan, Iran, or any federal sanctions regime relating to a foreign terrorist organization is not subject to
the contract prohibition.)
By signature on the Compliance Forms Signature Page, I certify and verify that Vendor is not on the Texas Comptroller's list
identified above; that this certification is true, complete and accurate; and that I am authorized by my company to make this
certification.
HISTORICALLY UNDERUTILIZED BUSINESS CERTIFICATION
A Proposer that has been certified as a Historically Underutilized Business (also known as a Minority/Women Business
Enterprise or "MWBE" and all referred to in this form as a "HUB") is encouraged to Indicate its HUB certification status when
responding to this Proposal Invitation. The BuyBoard website will indicate HUB certifications for awarded Vendors that
properly indicate and document their HUB certification on this form. Please check (v) all that annly:
❑ I certify that my company has been certified as a HUB in the following categories:
❑ Minority Owned Business ❑ women Owned Business
❑ Service -Disabled Veteran Owned Business (veteran defined by 38 U.S.C. §101(2), who has a
service -connected disability as defined by 38 U.S.C. § 101(16), and who has a disability rating
of 20% or more as determined by the U. S. Department of Veterans Affairs or Department of
Defense)
Certification Number: N/A
Name of Certifying Agency: N/A
0 My company has NOT been certified as a HUB.
ACKNOWLEDGEMENT OF BUYBOARD TECHNICAL REOUIREM ENTS
Vendor shall review the BuyBoard Technical Requirements included in this Proposal Invitation. By signature on the Compliance
Forms Signature Page, the undersigned affirms that Proposer has obtained a copy of the BuyBoard Technical Requirements,
has read and understands the requirements, and certifies that Vendor is able M meet and will comply with those requirements
except as follows: [Listand eap/am BuyBoard Tedwica/Requirements, ifany, to which yourcompany cannot or wd/nar
comply]
wA -We Wil mmpb
Note: In accordance with the General Tens and Conditions of the Contract, to the extent Vendor is awarded a Contract
under this Proposal Invitation but is unable or unwilling to meet the applicable BuyBoard Technical Requirements, the
information available on the BuyBoard for Vendor's awarded products or services may be limited, potentially placing Vendor
at a disadvantage and impacting the ability of Cooperative members to search, find, review, and purchase Vendor's awarded
products and services on the BuyBoard website. Further, to the extent Vendor has acknowledged ability to meet and comply
with the BuyBoard Technical Requirements, any subsequent failure or refusal by Vendor to promptly provide information
upon request to the Cooperative administrator in accordance with those technical requirements may be deemed an event of
default under the Contract. Initial: SHW
Page 15 of 71
PMXO Foams Cpmm�vwllm1
Board-
PURCNASJWG CCOPERATWE
MW Research Boulevard I Austin, fexds /8/59-Z439 ' PH: 8UU-b95-2919 ' buybuard.curn
CONSTRUCTIUN- RELATED GOODS AND SERVICES AFFIRMATION
'The Lucipetative issued the BuyBuard PIULUrement and LunstruLtiun-Related uuuds and Services Advisury fu, I exas Members
("Advisury"), which provides infuimatiUn specifically relevant to the PIULUleMent of Lunstructiun-related guuds and Services
by Texas Luluperative members. The Advisury, available at buyl3uai'd.LUm/Veridui/Resuui'LeS.aSUX, pi,uvides an uverview of
certain legal requirements that are putentially relevant to a Cooperative member's procurement of LUnStl'ULtiUn or
cunstruLtiun-i elated guuds and services, including thuse fur piujeas that may invulve or require architecture, engineering or
independent testing services. A LUPY of the Advisory can alsu be provided upon request. Because many BuyBuard contracts
include guuds ui installatiun services that might be LUnsideied curistructiun-related, Proposer must make this Lunstructiun
Belated -Goods and Services Affirmatiun regardless of type of guuds UV Services associated with this Prupusal invitatiun.
A cuntract awarded under this Prupusal invitatiun LUVel S only the Specific guuds andjui see vices awarded by the Cuuperative.
As explained in the Advisury ("Advisury"), Texas law prohibits the procurement of architecture or engineering
services through a purchasing cooperative. This Proposal invitation and any Contract awarded thereunder
does not include such services. Architecture or engineering services must be procured by is Cooperative
member separately, ii I -- d"- i,ze with the Protessiondi Services Procurement Act (Chapter ZZS4 of the Texas
Government Code) "11111LI 4Ln—i —1,jAcabL; 1"w and local policy.
By signature un the Compliance fUVMS Signdtui e Page, Pi upusei dffii ms that Pwpusei has obtained a LUPY of the Advisui y,
has read and understands the Advisury, and is authudzed by Prupuser to make this affirmation. if Proposer sells LunStl-ULdUn-
related guuds Ul'SelViLeS W a Luuperative member under a CuntraLt awarded under this Prupusal Invitatiun, Prupuser will
comply with the Advisury and applicable legal requirements, make a guud faith effurt to make its Lulupetative member
custumers ur putential Luupei ative member custumet s aware of such requirements, and provide a Calupet ative member with
a cupy of the Advisury befure accepting the member's Purchase Order ur uther agreement fUl'Lunstructiun-related guuds ur
services.
initial: SHW
Page lb Ut A
Proposal Forrus LUMM/Sy-LS v.08.11.2021
PT Boarda
Fuxexpavrm cuaPrxanrr
12007 Research Boulevard • Austin, Texas 78759-2439 • PH: 800-695-2919 • huvboard.com
DEVIATION AND COMPLIANCE
If your company intends to deviate from the General Terms and Conditions, Proposal Specifications or other requirements
associated with this Proposal Invitation, you MUST list all such deviations on this form, and provide complete and detailed
information regarding the deviations on this form or an attachment to this form. Prior to completing this form, Vendor
shall review the General Terms and Conditions section B.4 (Deviations from Item Specifications and General
Terms and Conditions). Please note that, as provided in section B.4, certain provisions of the General Terms
and Conditions are NOT subject to deviation, and certain deviations will be deemed rejected without further
action by the Cooperative. Any attempted deviation, whether directly or indirectly, to provisions identified in
this Proposal Invitation as not subject to deviation shall be deemed rejected by the Cooperative and, unless
otherwise withdrawn by Vendor, may result in Vendors Proposal being rejected in its entirety.
The Cooperative will consider any deviations in its contract award decision and reserves the right to accept or reject a proposal
based upon any submitted deviation.
In the absence of any deviation identified and described in accordance with the above, your company must fully comply with
the General Terms and Conditions, Proposal Specifications and all other requirements associated with this Proposal Invitation
if awarded a Contract under this Proposal Invitation. A deviation will not be effective unless accepted by the Cooperative.
The Cooperative, by and through the Cooperative administrator, may, in Its sole discretion, seek clarification from and/or
communicate with Proposer(s) regarding any submitted deviation, consistent with general procurement principles of fair
competition. The Cooperative reserves the right to accept or reject a Proposal based upon any submitted deviation.
Please oheok (%/) nne of the fnllnwinm-
M NO; Deviations
❑ Yes; Deviations
List and fully explain any deviations you are submitting:
No Deviations
Page 17 of 71
Initial: SHW
PMXWroams COMMr vW11121
PT Boarda
Fuxexpavrm cuarrxanrr
12007 Research Boulevard • Austin, Texas 78759-2439 • PH: 800-695-2919 • buvboard.com
VENDOR CONSENT FOR NAME BRAND USE
BuyBoard members seeking to make purchases using a Contract awarded under this Proposal Invitation may view information
regarding awarded Vendors, including but not limited to product catalogs, pricelists, pricing, and Proposals, through the
BuyBoard website. To improve and enhance the experience of BuyBoard members seeking to procure goods and services
under the Contract utilizing the BuyBoard website, any Vendor logo, product Images, and similar brand and trademark
information provided by Vendor for purposes of the Contract ("Vendor Information'D may be posted on the BuyBoard website.
You acknowledge that, by submitting your Proposal, unless you specifically opt out below, you consent to use
of your company's Vendor Information on the BuyBoard website if awarded a Contract. You further acknowledge
that whether, where, and when to include the Vendor Information on the BuyBoard website shall be at the sole discretion of
the BuyBoard Administrator. Vendor retains, however, the right of general quality control over the BuyBoard Administrator's
authorized display of proprietary Vendor Information. Neither the BuyBoard nor its administrator will be responsible for the
use or distribution of Vendor Information by BuyBoard members or any other third party using the BuyBoard website. This
Vendor Consent shall be effective for the full term of the Contract, including renewals, unless Vendor provides a signed,
written notice revoking consent to mntJartadmin�alhuvhnard.mm. BuyBoard shall have up to thirty days from the date of
receipt of a termination or revocation of a Vendor t:onsent to remove Vendor information from the BuyBoard website.
This Vendor Consent is subject to the Terms and Conditions of the Contract, including, but not limited to, those terms
pertaining to Disclaimer of Warranty and Limitation of Liability, Indemnification, and Intellectual Property Infringement.
Vendor logo files must be submitted in one of the formats set forth in the BuyBoard Technical Requirements. Proposers are
requested to submit this information with Vendor's Proposal. (This consent shall not authorize use of your company's Vendor
Information by BuyBoard if your company is not awarded a Contract.)
OPT OUT:
If your company wishes to opt out of the Vendor Consent for Name Brand Use, you must check the opt out tax below. DO
NOTselect this box unless your company is opting out of this Vendor Consent for Name Brand Use.
❑ By checking this box, Vendor hereby declines to provide consent for use of Vendor Information (as defined herein) on
the BuyBoard website. By opting out, Vendor ackndnslotlgae BadlagveielaElhat, if Vendor is awarded a Contract
under this Proposal Invitation, information avdill R d.eBiB BuyBoard for Vendor's awarded products or
services may be limited, potentially placing Vendor at a disadvantage and impacting the ability of
Cooperative members to search, find, review, and purchase Vendor's awarded products and services on the
BuyBoard website.
initial: SHW
Page 18 of 71
pmxp ramsCOMW/ av�llM1
PT Boarda
Fuxexpavrm cucPcxanrE
12007 Research Boulevard • Austin, Texas 78759-2439 • PH: 800-695-2919 • buvboard.com
CONFIDENTIAL/ PROPRIETARY INFORMATION
A. Public Disclosure Laws
All Proposals, forms, documentation, catalogs, pricelists, or other materials submitted by Vendor to the Cooperative in
response to this Proposal Invitation, may be subject to the disclosure requirements of the Texas Public Information Act (Texas
Government Code chapter 552.001, et, seq.) or similar disclosure law. Proposer must clearly identify on this form any
information In its Proposal (including forms, documentation, or other materials submitted with the Proposal) that Proposer
considers proprietary or confidential. If Proposer fails to properly identify the Information, the Cooperative shall have no
obligation to notify Vendor or seek protection of such information from public disclosure should a member of the public or
other third party request access to the information under the Texas Public Information Act or similar disclosure law. When
required by the Texas Public Information Act or other disclosure law, Proposer may be notified of any third -party request for
information in a Proposal that Proposer has identified In this form as proprietary or confidential.
Does your Proposal (including forms, documentation, catalogs, pricelists, or other materials submitted with the Proposal)
contain information which Vendor considers proprietary or confidential?
Please check fJl one of Ne folimina:
ONO, I certify that none of the information included with this Proposal is considered confidential or proprietary.
YES, I certity that this Proposal contains information considered confidential or proprietary and all such information is
specifically identified on this form.
If you responded "YES", you must clearly identify below the specific Information you consider confidential or proprietary. List
each page number, form number, or other information sufficient to make the information readily identifiable. The Cooperative
and Cooperative administrator shall not be responsible for a Proposer's failure to clearly identify information considered
confidential or proprietary. Further, by submitting a Proposal, Proposer acknowledges that the Cooperative and Cooperative
administrator will disclose information when required by law, even if such Information has been identified herein as
information Vendor considers confidential or proprietary.
Confidential / Proprietary Information:
N/A - None
(AtG.iri xdibnaishah: ifnea*1)
Page 19 of 71
Initial: SHW
PmXW�m5COmm�vW11121
PFROM x9a
12007 Research Boulevard • Austin, Texas 78759-2439 • PH: 800-695-2919 • buvboard.com
B. Convriaht Information
Does your Proposal (including forms, documentation, pricelists, catalogs, or other materials submitted with the Proposal)
contain copyright information?
ONOr Proposal (including forms, documentation, pricelists, catalogs, or other materials submitted with the Proposal) does not
contain copyright information.
❑ YES, Proposal (including forms, documentation, pricelists, catalogs, or other materials submitted with the Proposal) does
contain copyright information.
If you responded "YES", clearly identify below the specific documents or pages containing copyright information.
Copyright Information: N/A - None
(Attu ac(i'.a'ra/shexs ifn�t )
C. Chnserrt to Release CmRdential/Pmrr ietam/Caovriaht Infarrnation to BuyBoard Members
BuyBoard members (Cooperative and nonprofit members) seeking to make purchases through the BuyBoard may wish to
view information included in the Proposals of awarded Vendors. If you identified information on this form as confidential,
proprietary, or subject to copyright, and you are awarded a BuyBoard contract, your acceptance of the BuyBoard contract
award constitutes your consent to the disclosure of such Information to BuyBoard members, including posting of such
information on the secure BuyBoard website for members. Note: Neither the Cooperative nor Cooperative administrator will
be responsible for the use or distribution of information by BuyBoard members or any other party.
D. Consent tf� Rele7 I Ta Ia6i�tn
Notwithstanding anything in t is Con dentlal/Proprietary Information form to the contrary, by submitting a Proposal, Vendor
consents and agrees that, upon Contract award, the Cooperative may publicly release, including posting on the public
BuyBoard website, a copy of the proposal tabulation and award Information forthe Contract including Vendor name; proposed
catalog/pricelist name(s); proposed percentage discount(s), hourly labor rate(s), or other specified pricing; and Vendor award
or non -award information.
Initial: SHW
Page 20 of 71
PNWWrom5MMM1 vW11M1
PT Boarda
Fuxexpavrm cuaPrxamr
12007 Research Boulevard • Austin, Texas 78759-2439 • PH: 800-695-2919 • buvboard.com
EDGAR VENDOR CERTIFICATION
(2 CFR Part 200 and Appendix II)
When a Cooperative member seeks to procure goods and services using funds under a federal grant or contract, specific
federal laws, regulations, and requirements may apply in addition to those under state law. This includes, but is not limited
to, the procurement standards of the Uniform Administrative Requirements, Cost Principles and Audit Requirements for
Federal Awards, 2 CFR 200 (sometimes referred to as the "Uniform Guidance" or new "EDGAWD. All Vendors submitting a
Proposal must complete this EDGAR Certification Form regarding Vendor's willingness and ability to comply with certain
requirements which may be applicable to specific Cooperative member purchases using federal grant funds. Completed
forms will be made available to Cooperative members for their use while considering their purchasing options when using
federal grant funds. Cooperative members may also require Vendors to enter into ancillary agreements, in addition to the
terms and conditions of the BuyBoard contract, to address the member's specific contractual needs, including contract
requirements for a procurement using federal grants or contracts.
Foreach of the items below, Vendor should certify Vendor's agreement and ability to comply, where
applicable, by having Vendor's authorized representative check the applicable boxes, initial each page, and
sign the Compliance Forms Signature page, if you fail to complete any item in this form, the Cooperative will
consider and may list the Vendor's response on the BuyBoard as " NO, "the Vendor is unable or unw illing to
comply. A "NO" response to any of the items may, if applicable, impact the ability of a Cooperative member to purchase
from the Vendor using federal funds.
1. Vendor Violation or Breach of Contract Terms:
Contracts for more than the simplified acquisition threshold, which is the inflation adjusted amount determined by the Civilian
Agency Acquisition Council and the Defense Acquisition Regulations Council (Councils) as authorized by 41 USC 1908, must
address administrative, contractual, or legal remedies in instances where contractors violate or breach contract terms, and
provide for such sanctions and penalties as appropriate.
Provisions regarding Vendor default are included in the BuyBoard General Terms and Conditions, including Section E.18,
Remedies for Default and Termination of Contract. Any Contract award will be subject to such BuyBoard General Terms and
Conditions, as well as any additional terms and conditions in any Purchase Order or Cooperative member ancillary contract
agreed upon by Vendor and the Cooperative member which must be consistent with and protect the Cooperative member at
least to the same extent as the BuyBoard Terms and Conditions. The remedies under the Contract are in addition to any
other remedies that may be available under law or in equity. By submitting a Proposal, you agree to these Vendor violation
and breach of contract terms.
M YES, I agree. ❑ NO, I do not agree
2. Termination for Cause or Convenience:
For any Cooperative member purchase or contract in excess of $10,000 made using federal funds, you agree that the following
term and condition shall apply:
The Coope7ative membermayterminate oroncel anyRim%25e tkderunderMSConhadatanytimG wide or vvlihoutceusg
byproviding seven (7) business days advance written notice to the Vendor. ifdlisAgreementis terminated in accordance
with this Paragraph, the Cooperatme membershall onlybe required to pay Vendorforgoodsorservices delivered to the
Cooperatf✓e memberpnorto the termination and notoffi&mse returned in accordance with VendM; ra!um poixy. ifMe
Cooperative memberhas paid Vendor forgoods orsemcesnot yetprovided as ofdfe date of tennination, Vendorshall
immediatelyrefundsuch payment(s).
If an alternate provision for termination of a Cooperative member purchase for cause and convenience, including the manner
by which It will be effected and the basis for settlement, is included In the Cooperative member's Purchase Order or ancillary
agreement agreed to by the Vendor, the Cooperative member's provision shall control.
I YES, I agree. ❑ NO, I do not agree. Initial: SHW
Page 21 of 71
PMXWroM5MMM�VM11M1
PFROME4a
12007 Research Boulevard • Austin, Texas 78759-2439 • PH: 800-695-2919 • buvboard.com
3. Equal Employment Opportunity:
Except as otherwise provided under 41 CFR Part 60, all Cooperative member purchases or contracts that meet the definition
of "federally assisted construction contract" in 41 CFR Part 60-1.3 shall be deemed to include the equal opportunity clause
provided under 41 CFR 60-1.4(b), in accordance with Executive Order 11246, "Equal Employment Opportunity" (30 FR 12319,
12935, 3 CFR Part, 1964-1965 Comp., P. 339), as amended by Executive Order 11375, "Amending Executive Order 11246
Relating to Equal Employment Opportunity," and implementing regulations at 41 CFR Part 60, "Office of Federal Contract
Compliance Programs, Equal Employment Opportunity, Department of Labor."
The equal opportunity clause provided under 41 CFR 60-1.4(b) is hereby Incorporated by reference. Vendor agrees that such
provision applies to any Cooperative member purchase or contract that meets the definition of"federally assisted construction
contract" in 41 CFR Part 60-1.3 and Vendor agrees that R shall comply with such provision.
I YES, I agree. ❑ NO, I do not agree.
4. Davis -Baron Act:
When required by Federal program legislation, Vendor agrees that, for all Cooperative member prime construction
contracts/purchases in excess of $2,000, Vendor shall comply with the Davis -Bacon Act (40 USC 3141-3144, and 3146-3148)
as supplemented by Department of Labor regulations (29 CFR Part 5, "Labor Standards Provisions Applicable to Contracts
Covering Federally Financed and Assisted Construction'). In accordance with the statute, Vendor is required to pay wages to
laborers and mechanics at a rate not less than the prevailing wages specified in a wage determinate made by the Secretary
of Labor. In addition, Vendor shall pay wages not less than once a week.
Current prevailing wage determinations issued by the Department of Labor are available at beta.sam.gov. Vendor agrees
that, for any purchase to which this requirement applies, the award of the purchase to the Vendor is conditioned upon
Vendor's acceptance of the wage determination.
Vendor further agrees that it shall also comply with the Copeland "Anti -Kickback" Act (40 USC 3145). as supplemented by
Department of Labor regulations (29 CFR Part 3, "Contractors and Subcontractors on Public Building or Public Work Financed
in Whole or in Part by Loans or Grants from the United States'). The Act provides that each contractor or subreciplent must
be prohibited from inducing, by any means, any person employed in the construction, completion, or repair of public work,
to give up any part of the compensation to which he or she is otherwise entitled.
LA YES, I agree. ❑ NO, I do not agree
S. Contract Work Hours and Safety Standards Act:
Where applicable, for all Cooperative member contracts or purchases in excess of $100,000 that involve the employment of
mechanics or laborers, Vendor agrees to comply with 40 USC 3702 and 3704, as supplemented by Department of Labor
regulations (29 CFR Part 5). Under 40 USC 3702 of the Act, Vendor Is required to compute the wages of every mechanic and
laborer on the basis of a standard work week of 40 hours. Work in excess of the standard work week is permissible provided
that the worker Is compensated at a rate of not less than one and a half times the basic rate of pay for all hours worked in
excess of 40 hours in the work week.
The requirements of 40 USC 3704 are applicable to construction work and provide that no laborer or mechanic must be
required to work in surroundings or under working conditions which are unsanitary, hazardous or dangerous. These
requirements do not apply to the purchases of supplies or materials or articles ordinarily available on the open market, or
contracts for transportation or transmission of intelligence.
11 YES, I agree. ❑ NO, I do not agree
initial: SHW
Page 22 of 71
Pmrq�f"SNMM1 VW11AR1
PFBoarda
uxcxpavrm cuwsx�nvr
12007 Research Boulevard • Austin, Texas 78759-2439 • PH: 800-695-2919 • buvboard.com
6. Right to Inventions Made Under a Contract or Agreement:
If the Cooperative member's Federal award meets the definition of "funding agreement" under 37 CFR 401.2(a) and the
recipient or subrecipient wishes to enter into a contract with a small business firm or nonprofit organization regarding the
substitution of parties, assignment or performance or experimental, developmental, or research work under that "funding
agreement;'the recipient or subrecipient must comply with the requirements of 37 CFR Part 401, "Rights to Inventions Made
by Nonprofit Organizations and Small Business Firms Under Government Grants, Contracts and Cooperative Agreements;'
and any implementing regulations issued by the awarding agency.
Vendor agrees to comply with the above requirements when applicable.
11 YES, I agree. ❑ NO, I do not agree
7. Clean Air Act and Federal Water Pollution Control Act:
Clean Air Act (42 USC 7401-7671q.) and the Federal Water Pollution Control Act (33 USC 1251-1387), as amended —Contracts
and subgrants of amounts in excess of $150,000 must contain a provision that requires the non -Federal award to agree to
comply with all applicable standards, orders, or regulations issued pursuant to the Clean Air Act (42 USC 7401-7671q.) and
the Federal Water Pollution Control Act, as amended (33 USC 1251-1387). Violations must be reported to the Federal
awarding agency and the Regional Office of the Environmental Protection Agency (EPA).
When required, Vendor agrees to comply with all applicable standards, orders, or regulations issued pursuant to the Clean
Air Act and the Federal Water Pollution Control Act.
LM YES, I agree. ❑ NO, I do not agree.
8. Debarment and Suspension:
Debarment and Suspension (Executive Orders 12549 and 12689) —A contract award (see 2 CFR 180.220) must not be made
to parties listed on the government -wide exclusions in the System for Award Management (SAM), in accordance with the
OMB guidelines at 2 CFR 180 that implement Executive Orders 12549 (3 CFR Part 1966 Comp. p. 189) and 12689 (3 CFR
Part 1989 Comp. p. 235), "Debarment and Suspension." SAM Exclusions contains the names of parties debarred, suspended,
or otherwise excluded by agencies, as well as parties declared ineligible under statutory or regulatory authority other than
Executive Order 12549.
Vendor certifies that Vendor is not currently listed on the government -wide exclusions in SAM, is not debarred, suspended,
or otherwise excluded by agencies or declared ineligible under statutory or regulatory authority other than Executive Order
12549. Vendor further agrees to Immediately notify the Cooperative and all Cooperative members with pending purchases or
seeking to purchase from Vendor if Vendor is later listed on the government -wide exclusions in SAM, or is debarred,
suspended, or otherwise excluded by agencies or declared ineligible under statutory or regulatory authority other than
Executive Order 12549.
11 YES, I agree. ❑ NO, I do not agree.
9. Byrd Anti -Lobbying Amendment:
Byrd Anti -Lobbying Amendment (31 USC 1352) - Vendors that apply or bid for an award exceeding $100,000 must file the
required certification. Each der certifies to the tier above that It will not and has not used Federal appropriated funds to pay
any person or organization for influencing or attempting to influence an officer or employee of any agency, a member of
Congress, officer or employee of Congress, or an employee of a member of Congress in connection with obtaining any Federal
contract, grant or any other award covered by 31 USC 1352. Each der must also disclose any lobbying with non -Federal funds
that takes place in connection with obtaining any Federal award. Such disclosures are forwarded from tier to tier up to the
non -Federal award. As applicable, Vendor agrees to file all certifications and disclosures required by, and otherwise comply
with, the Byrd Anti -Lobbying Amendment (31 USC 1352).
11 YES, I agree. ❑ NO, I do not agree
Initial: SHW
Page 23 of 71
Pmwq r"SNmmI vW11A l
PT Boarda
Fuxexpavrm cucPrxanrr
12007 Research Boulevard • Austin, Texas 78759-2439 • PH: 800-695-2919 • buvboard.com
10. Procurement of Recovered Materials:
For Cooperative member purchases utilizing Federal funds, Vendor agrees to comply with Section 6002 of the Solid Waste
Disposal Act, as amended by the Resource Conservation and Recovery Act where applicable and provide such information
and certifications as a Cooperative member may require to confirm estimates and otherwise comply. The requirements of
Section 6002 include procuring only items designated in guidelines of the Environmental Protection Agency (EPA) at 40 CFR
Part 247 that contain the highest percentage of recovered materials practicable, consistent with maintaining a satisfactory
level of competition, where the purchase price of the item exceeds $10,000 or the value of the quantity acquired during the
preceding fiscal year exceeded $10,000; procuring solid waste management services In a manner that maximizes energy and
resource recovery, and establishing an affirmative procurement program for procurement of recovered materials Identified in
the EPA guidelines.
11 YES, I agree. ❑ NO, I do not agree.
11. Domestic Preferences for Procurements:
Where appropriate and consistent with law, 2 CFR §200.322 contains certain considerations for domestic preferences for
procurements which may be applicable to Cooperative members using federal funds. When required by a Cooperative
member, Vendor agrees to provide such Information or certification as may reasonably be requested by the Cooperative
member regarding Vendor's products, including whether goods, products, or materials are produced In the United States.
M YES, I agree. ❑ NO, I do not agree
12. Prohibition on Certain Telecommunications and Video Surveillance Services or Equipment
2 CFR §200.216 prohibits expending federal loan or grant funds to procure or obtain certain telecommunications and video
surveillance services or equipment. To the extent applicable and when required by a Cooperative member, Vendor agrees to
provide such information or certification as may reasonably be requested by the Cooperative member to confirm whether
any telecommunications or video surveillance services or equipment provided by Vendor Is covered equipment or covered
services under 2 CFR §200.216.
17 YES, I agree. ❑ NO, I do not agree.
13. Profit as a Separate Element of Price:
For purchases using federal funds in excess of the Simplified Acquisition Threshold, a Cooperative member may be required
to negotiate profit as a separate element of the price. See, 2 CFR 200.324(b). When required by a Cooperative member,
Vendor agrees to provide information and negotiate with the Cooperative member regarding profit as a separate element of
the price for a particular purchase. However, Vendor agrees that the total price, including profit, charged by Vendor to the
Cooperative member shall not exceed the awarded pricing, including any applicable discount, under Vendor's Cooperative
Contract.
11 YES, I agree. ❑ NO, I do not agree.
14. General Compliance and Cooperation with Cooperative Members:
In addition to the foregoing specific requirements, Vendor agrees, in accepting any Purchase Order from a Cooperative
member, R shall make a good faith effort to work with Cooperative members to provide such information and to satisfy such
requirements as may apply to a particular Cooperative member purchase or purchases including, but not limited to, applicable
recordkeeping and record retention requirements.
11 YES, I agree. ❑ NO, I do not agree
Initial: SHW
Page 24 of 71
Pmwq r"SNmmI vW11A l
PT Boarda
Fuxexpavrm cucPcxanyc
12007 Research Boulevard • Austin, Texas 78759-2439 • PH: 800-695-2919 • buvboard.com
COMPLIANCE FORMS SIGNATURE PAGE
By initialing pages and by signature below, I certify that I have reviewed the following forms; that the information provided
therein is true, complete, and accurate; and that I am authorized by my company to make all certifications, consents,
acknowledgements, and agreements contained herein:
• Proposal Acknowledgements
• Felony Conviction Disclosure
• Debarment Certification
• Resident/Nonresident Certification
• Vendor Employment Certification
• No Boycott Verification
• No Excluded Nation or Foreign Terrorist Organization Certification
• Historically Underutilized Business Certification
• Construction -Related Goods and Services Affirmation
• Acknowledgement of BuyBoard Technical Requirements
• Deviation and Compliance
• Vendor Consent for Name Brand Use
• Confidential/Proprietary Information
• EDGAR Vendor Certification
Pertormance Health Supply LLC , DBA Medim Supply Company
Co.mppaa"',
Company Name
Sign 3 ure of Aut
horized rized Company Official
Stephen Weiss - Sales Support Coordinator
Printed Name and Title
1 /23/2023
Date
Page 25 of 71
PmXWrams COmm�v12111@1
PT a Board
Fuxexpavrm cwPrxamr
12007 Research Boulevard • Austin, Texas 78759-2439 • PH: 800-695-2919 • buvboard.com
PROPOSAL FORMS PART 2: VENDOR INFORMATION FORMS
INSTRUCTIONS:
Proposer must completely and accurately provide all information requested in the following Vendor Information forms or
your Proposal may be rejected as non -responsive:
• Vendor Business Name
• Vendor Contact Information
• Federal and State/Purchasing Cooperative
Experience
• Governmental References
• Company Profile
• Texas Regional Service Designation
• State Service Designation
• National Purchasing Cooperative Vendor Award
Agreement (Ve dtvs mnngouorde ferasmly)
• Local/Authorized Seller Listings
• Manufacturer Dealer Designation
• Proposal Invitation Questionnaire
• Vendor Request to Self -Report BuyBoard
Purchases (opomai)
To the extent any information requested is not applicable to your company, you must so Indicate on the form.
VENDOR BUSINESS NAME
By submitting a Proposal, Vendor is seeking to enter into a legal contract with the Cooperative. As such, Vendor must be an
individual or legal business entity capable of entering into a binding contract.
Nameof Pr000sirrjj// Conn.., Performance Health Supply LLC , DBA Medco Supply Company
UR (Lthe�tna7m%e mmpaaymo&q to nxrtra.Y with the Caxeotw lb L6Z/atan ass eded e, dba, aka, elf. hem. Such nfomralaa may
be po"vedbbw.If)w are s hTdtw apntpgaysa/ wtY7 ambwe tty to poMde the sane prposedgwds a•mvxes, e'<rY stbdxv erW sm/af
cnrnpkdeaseparate wrjvbrnfam"n fam. Sewratefyoprahnglega/twsnessetbbes euasifaffi/iateds lrtra, whichpropuse toprowdegmdsor
ser vices sepretey must wbnit their own Proposals.)
Plax= rMr4 (4) nra of rf,p fnllrruim-
Noe of Business: ❑ Individual/Sole Proprietor ❑ Corporation Limited Liability Company ❑ Partnership
❑ Other (Specify: 1
State of Incornoration (if applicable): Illinois
Federal Emolover Identification Number: 36-4391091
(Pendormust include a rompletedIR4; W--9 tam with then ProFau/)
Name which Vendor. if awarded. wishes to be identified on the ByyBoard: (Note: IfdiRerr#Crantlre hHmeofPmpnsii(g
appAabk, rn abeaon/yua/id bade names(dGe,aka,eT:)ofbre Rapsmg CixnPanYmaY be used andampYofWurAssumcdAkme Certifxate(s). (f
appicab/e, mustba attached)
Medco Supply Company
Page 26 of 71
PMXWFoM5MMM( vW11121
Form Request for Taxpayer Give Form to the
(Rev. October Identification Number and Certification requester. Do not
Department of the Treasury send to the IRS.
Internal Revenue Service 1 Go to wwwJrs.gov1FormW9 for instructions and the latest information.
1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
Performance Health Holdings, Inc.
2 Business name/disregarded entity name, if different from above
Performance Health Supply, LLC dba Medco Supply, Masune & Surgical Supply Services (#20-4590834)
S Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the 4 Exemptions (codes apply only to
m
m following seven boxes. certain entities, not individuals; see
a instructions on page 3):
o ❑ Individualisole proprietor or d❑ C Corporation ❑ S Corporation ElPartnership ❑ Trust/estate
c single -member LLC Exempt payee code (if any) 5
a o
❑ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) ■
`o z Note: Check the appropriate box in the line above for the tax classiflcation of the single -member owner. flo not check Exemption from FATCA reporting
rn LLC if the LLC is classified as a single -member LLC that is disregarded from the owner unless the owner of the LLC is
S another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single -member LLC that Oode (if NIA
2 is disregarded from the owner should check the appropriate box for the tax classifcation of its owner.
y ❑ Other (see instructions) ■ 64acff� m eccourasmwnreh-douNkfe the us]
�j 5 Address (number, street, and apt. or suite no.) See instructions. Requester's name and address (optional)
�28100 Torch Parkway, Suite 800
8 City, state.- and ZIP code
WarrenviIle, IL 60655
7 List account number(s) here (optional]
Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid Social security number
backup withholding. For individuals, this is generally your social security number (SS". However, for a m
resident alien, sole proprietor, or disregarded entity, see the instructions for Part 1, later. For other ER
entities, it is your employer identification number (EIN), if you do not have a number, see How to get a
TIN, later. or
Note: If the account is in more than one name, see the instructions for line t. Also see What Name and Employer identification number
Number To Give the Requester for guidelines on whose number to enter. { II `` J
M36 WI 4Ikk 3I9 1 If}I �9I7
JjM Certification II
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a fail lure to report all interest or dividends, or (c) the IRS has notif led me that I am
no longer subject to backup withholding; and
3. 1 am a U.S. citizen or other U.S. person (defined below); and
4, The FATCA coda(a) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructlons. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because
you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid,
acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments
other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.
J
Sign Signature
Here U.S. person ■ Date ■
General Instrudions • Form 1099-DIV (dividends, including those from stocks or mutual
funds)
Section references are to the Internal Revenue Code unless otherwise
noted.
Future developments. For the latest information about developments
related to Form W-9 and its instructions, such as legislation enacted
after they were published, go to www.irs.gov1FonnW9.
Purpose of Form
An individual or entity (Form W-9 requester) who is required to file an
information return with the IRS must obtain your correct taxpayer
identification number (TIN) which may be your social security number
(SSN), individual taxpayer identification number (ITIN), adoption
taxpayer Identification number (ATIN), or employer identification number
(EIN), to report on an information return the amount paid to you, or other
amount reportable on an information return. Examples of information
returns include, but are not limited to, the following.
• Form 1099-INT (interest earned or paid)
• Form 1099-MISC (various types of income, prizes, awards, or gross
proceeds)
• Form 1099-B (stock or mutual fund sales and certain other
transactions by brokers)
• Form 1099-5 (proceeds from real estate transactions)
• Form 1099-K (merchant card and third party network transactions)
• Form 1098 (home mortgage interest), 1098-E (student loan interest),
1098-T (tuition)
• Form 1099-C (canceled debt)
• Form 1099-A (acquisition or abandonment of secured property)
Use Form W-9 only if you are a U.S. person (including a resident
alien), to provide your correct TIN.
if you do not return Form W-9 to the requester with a TIN, you might
be subject to backup withholding. See What is backup withholding,
later.
Cat. No. 10231X Form W-9 (Rev. 10-2018)
PT Boarda
Fuxexpavrm cooa:xamr
12007 Research Boulevard • Austin, Texas 78759-2439 • PH: 800-695-2919 • buvboard.com
VENDOR CONTACT INFORMATION
Vendor shall provide the requested Vendor Contact Information in the electronic proposal submission system
including contract, purchase order, RFQ, and invoice contacts (or i£submitting a hard copy proposal, timely
request and complete the Vendor Contact Information form in accordance with the Instructions to proposers).
FEDERAL AND STATE/PURCHASING COOPERATIVE EXPERIENCE
The Cooperative strives to provide Cooperative members with the best services and products at the best prices available from
Vendors with the technical resources and ability to serve Cooperative members. Please respond to the following questions.
1. Provide the dollar value of sales to or through purchasing cooperatives at or based on an established catalog or market
price during the previous 12-month period or the last fiscal year: $ (The period of the 12-month
period is / ). In the event that a dollar value Is not an appropriate measure of the sales, provide
and describe your own measure of the sales of the Item(s).
2. By submitting a proposal, you agree that, based on your written discounting policies, the discounts you offer the
Cooperative are equal to or better than the best price you offer other purchasing cooperatives for the same items under
equivalent circumstances.
3. Provide the Information requested below for other purchasing cooperatives for which Proposer currently serves, or in
the past has served, as an awarded vendor. Rows should be added to accommodate as many purchasing cooperatives
as required.
2. T-PASS (state of Texas)
3. OMNIA Partners
4. Sourcewell (RIPA)
5. E&I Cooperative
6. Houston -Galveston Area Council (HGAC)
7. Choice Partners
8. The Interlocal Purchasing System (TIPS)
9. Other
y
Yes. We've been Awarded
nnw fnr 2 yyaars 2�2ry 2(172
Yes, WeVA been AWardAa
y
nnwfnr4Pars. 2018-2022
Y
Yes, We'3 been awarded
ri a fnr 5 Yearc_ 2017-2022
EP11-20
Emeneenryency & Safety Eguipmei t
22N07KN HealhNetlsal Sup¢lies
200804 Medical Supplies
❑ MY COMPANY DOES NOT CURRENTLY HAVE ANY OF THE ABOVE OR SIMILAR TYPE CONTRACTS.
CURRENT BUYBOARD VENDORS
If you are a current BuyBoard vendor in the same contract category as proposed in this Proposal Invitation, indicate the
discount for your current BuyBoard contract and the proposed discount in this Proposal. Explain any difference between your
current and proposed discounts.
Current Discount(°!o): 0-25% Proposed Discount(x/o): 0-25%
Exnlanatinn• No Difference
Page 27 of 71
PMXW roM500MMISVGiv f 111@1
PT Boarda
Fuxexpavrm cuaPrxamr
12007 Research Boulevard • Austin, Texas 78759-2439 • PH: 800-695-2919 • buvboard.com
GOVERNMENTAL REFERENCES
For your Proposal to be considered, you must supply a minimum of five (5) individual governmental entity references. The
Cooperative may contact any and all references provided as partof the Proposal evaluation. Provide the information requested
below, including the existing pricing/discounts you offer each customer. The Cooperative may determine whether
pricing/discounts are fair and reasonable by comparing pricing/discounts stated in your Proposal with the pricing/discounts
you offer other governmental customers. Attach additional pages if necessary.
Quantity/
Entitv Name Contact Phone* Email Address Discount Volume
1. Dallas Baptist University
Courtney Pinson
Pearland ISD
2. Pearland Hinh School
WIII Ryan
Baylor Scott &
3. White Institute For Rehab
Kendall Goldberg
Klein ISD
4. Klein Cain Hiah School
Phil Banish
Brazosport ISD
Houston
5. Brazoswood Rich School
Peooer
214-3335667
Coudneyp@dbu We
281-997-3250
Ryanw@pearlandlsd org
4o9-265-5200
Kuldberg@BSWRehab corn
0.25 % Ott eady Athletic Training Supplies
$25 000 / Year
Yearly Athletic Training Supplies
0.25%Off $40,000I Year
Yearly Athletic Training Supplies
0.25%Off $25,000/Year
Yearly Athletic Training Supplies
316-209-1291
phi18107@gmail com 0-25%Off $35,000/Year
979-730.7305 Yearly Athletic Training Supplies
Ext. 29396 Houston oepper5swosoonsd net 0-25%Off $25,000/Year
Do you ever modify your written policies or standard governmental sales practices as identified in the above chart to give
better discounts (lower pricing) than indicated? YES LJ NO❑ If YES, please explain:
COMPANY PROFILE
Information on awarded Cooperative Contracts is available to Cooperative Members on the BuyBoard website. If your
company is awarded a Contract under this Proposal Invitation, please provide a brief company description that you would
like to have included with your company profile on the BuyBoard website. Submit your company profile in a separate
file, in Word format, with your Proposal. (Note: Vendor is solely responsible for any content provided for inclusion on
the BuyBoard website. The Cooperative reserves the right to exclude or remove any content in its sole discretion, with or
without prior notice, including but not limited to any content deemed by the Cooperative to be inappropriate, irrelevant to
the Contract, inaccurate, or misleading.)
Page 28 of 71
PNppsal Lo,ms COMM/$V6 v � 111@ 1
Contact Information
Medco Sports Medicine
28100 Torch Parkway, Suite 800
Wamenville, IL 60555
BOG-55-MEDCO
medmathletics.com
Your Representative:
Sales Support
Email:
metlms9essupparupme supplyinn
Phone:
800-556-3326
ProwderofAthletic Training, Sports Performance, and Strength & Conditioning
Supplies & Equipment
We are the nation's largest manufacturer and distributor of supplies and equipment to
professionals in athletic training, strength & conditioning, and sports performance
industry. We have the most comprehensive
breadth of products available through our
owned brands and vendor relationships.
Built on providing outstanding customer service
through experienced sales and support representatives,
we always go above and beyond
for our customers. For over 60 years we
have been helping the sports medicine industry
feel good, perform better and live their
best.
Core Competencies
Differentiators
Athletic Tape
�� More than 25,000 products
Athletic Training Kits, Bags & Cases
including hard -to -find specialty items
Athletic Training Room Furniture
Largest Sports Medicine Catalog
Bandages & Wound Dressings
both print and online
Casting & Splinting
Best in Class Digital capability
�'� g
Emergency Response
mobile order processing
First Aid & Health Education
EDI and Punchout solutions
Infection Prevention
v Sales Representation
Medical Diagnostics & Instruments
to provide support in every state
Medications & Topicals
Orthopedic Braces & Supports
Dedicated Customer Service
Protective Gear & Apparel
Experienced professionals
Rehabilitation & Exercise
available 24/7
Rehydratlon & Heat Stress Relief
jjg�? CELI s & Clinical Research
Strength Training & Cardio
Performance Health Academy
Therapeutic Modalities
BOC Approved Provider
Trusted brands owned by Medco Sports Medicine
ATHERABAND
Zia �ii ri
rolyan ((cmetrorr
Trusted brands distributed by Medco Sports Medicine
Andover
Hartman Conco
Athletic Edge
Hypertce
BSN
Jaybird
DJO&Chattanooga
Johnson&Johnson
Dukal
Kinematic Sports
Game Ready
McDavid
Gatorade
Medique
Pochmar
MedPac
Shock Doctor
Mueller
Under Armour
Normatec
Whitehall
Oakworks
Pro Orthopedic
Powerade
PT Boarda
Fua:xpavrm cucPrxamr
12007 Research Boulevard • Austin, Texas 78759-2439 • PH: 800-695-2919 • buvboard.com
TEXAS REGIONAL SERVICE DESIGNATION
71iis form must be completed in the electronic proposal submission system Lie& if ubmittinq a hard cony
Proposal, timely reouest and comolete the form in accordance with the Instructions to pr000sers),
The Cooperative (referred to as "Texas Cooperative" In this form and in the State Service Designation form) offers vendors
the opportunity to service its members throughout the entire State of Texas. In the electronic proposal submission system,
you must indicate if you will service Texas Cooperative members statewide or, if you do not plan to service all Texas
Cooperative members statewide, you must indicate the specific regions you will service. If you propose to serve different
regions for different products or services included in your Proposal, you must complete and submit a separate Texas Regional
Seance Designation form for each group of products and clearly indicate the products or services to which the designation
applies. (Additional forms can be obtained by contacting bldsCa)buvIboard.com at least five (S) business days/prior to
the Proposal Due Date.). By designating a region or regions, you are certifying that you are authorized and willing
to provide the proposed products and services in those regions. Designating regions in which you are either
unable orunwilling to provide the specified products and services shall be grounds for either rejection of your
Proposal of if awarded, termination of your Contract Additionally, it you do not plan to service Texas Cooperative
members (i.e., if you will service only states other than Texas). you must so indicate on the form in the electronic Dronosal
2 hmissinn system_
Regional Education Service Centers
$@pion and Headquarter@
1
Edinburg
2
Corpus Christi
3
Victoria
4
Houston
5
Beaumont
6
Huntsville
7
Ugore
8
Mount Pleasant
9
Wichita Falls
10
Richardson
11
Fort Worth
12
Waco
13
Austin
14
Abilene
15
San Angelo
16
Amarillo
17
Lubbock
18
Midland
19
El Paso
20
San Antonio
Page 29 of 71
PNWs roams COmm�vf111@1
Board
PYRCNISINC COOPPRIr1VE
12007 Research Boulevard . Austin, Texas 78759-2439 - PH: 800-695-2919 , buvbwrd.com
STATE SERVICE DESIGNATION
7his form must be completed in the electronic proposal submission system (or, ifsubmittina a hard cony
Proposal, timely request and complete the in accordance with the Instructions to Pronosers).
As set forth in the Proposal Invitation, it is the Cooperative's intent that other governmental entities in the United States have
the opportunity to purchase goods or services awarded under the Contract, subject to applicable state law, through a piggy-
back award or similar agreement through the National Purchasing Cooperative BuyBoard. If you plan to service the entire
United States or only specific states, you must comolete the State Servicej��lpnation information in the a ctronic or000sal
a,hm�sa'nn `I,crEm.(Note; If you plan to,ser ice Texas Cooperative members, besure thatYou comp) Texas Regional
�" rnce �ignation form.) In addition to this form, to be considered for a piggy -back award by the National
Purchasing Cooperative, you must have an authorized representative sign the National Purchasing
Cooperative VendorAward Agreement that follows this page.
If you serve different states for different products or services included in your Proposal, you must complete and submit a
separate State Service Designation form for each group of products and clearly indicate the products or services to which the
designation apphes. (Additional forms can be obtained by contacting hldstilhuvh� (d.cwn at least five (5) business
dayspnor to the Pro I Due Date.) By designating a state or states, you are certiYying that you are authorized
and willing to provide the proposed products and services in those states. Designating states in which you are
either unable or unwilling to provide the specified products and services shall begrounds for either rejection
ofyour Proposal or, ifawarded, termination ofyour Contract.
0 I will service all states In the United States.
• I will not service all states in the United States.
RNWIT,
Alaska
Nebraska
Arizona
Nevada
Arkansas
New Hampshire
California (Public Contract Code 20118 & 20652)
New Jersey
Colorado
New Me)dco
Connecticut
New York
Delaware
North Carolina
District of Columbia
North Dakota
Honda
Ohio
Georgia
Oklahoma
Hawaii
Oregon
Idaho
Pennsylvania
Illinois
Rhode Island
Indiana
South Carolina
Iowa
South Dakota
Kansas
Tennessee
Kentucky
Texas
Louisiana
Utah
Maine
Vermont
Maryland
Virginia
Massachusetts
Washington
Michigan
West Virginia
Minnesota
Wisconsin
Mississippi
Wyoming
Missouri
Montana
Page 30d]1 Pm+osai F° s comm�ucs Vw 11 n2l
WW
Board
URrhASiNG C&OPERATWE
MW Research Buulevard I Austin, exas /8/59-2439 - Pm: 800-695-2919 1 buybuard.cum
NATLUMAL PURCHASING COOPERATIVE VENuuk Aku AGREEMENT
in accut dance with the Tei ms and Conditions associated with this Prupusal invitation, a contract awarded under this Prupusal
invitation may be: "piggy -backed" by anuthei, governmental entity. The National Purchasing Cucipei'ative is an
interguvernmental purchasing cooperative fui'med by certain school districts outside of exas to sei've its members thi,uughuut
the United States. it you agree to be considered fur a piggy -back award by the National Purchasing Cooperative, you agree
to the following terms and agiee to Serve National Purchasing Wupetative members in the States you have indicated on the
State Set -vice Designation fui'm, in your Proposal.
By signing this f;,-rm, Proposer (referred to in this Agreement as "Vendor") agrees as f 11lows:
1. Vendui acknowledges that it 'fhe Local Guveinment Purchasing Cucipeiative ("fexas Lucipeiative") awaids Vendui- a
cunti-act under this Proposal invitation ("Underlying Award"), the National Purchasing Cooperative ("National Cooperative")
may - but is not required to - "piggy -back" on ui re -award all ur a puiticin of that Underlying Award ("Piggy -Back Award").
By signing this National Cooperative Vendur Awaid Agreement ("Agreement"), Vendor accepts and agrees to be buund by
any such Piggy -Back Award as provided fur herein.
2. in the event Natiunal Cuupei ative awai ds Vendui a Piggy -Back Award, the National Cuupei ative Administi-atul ("BuyBual d
Administi-atui-") will notify Vendui, in writing of such Piggy -Back Awai'd, which award shall CUMMenLe on the effective date
stated in the Notice and end on the exph-atiun date of the Underlying Award, Subject to annual renewals as authudzed in
writing by the BuyBuard Administiatur. Vendur agrees that no fluithet Signature ur uthet adiun is required of Vendor in urdel,
for the Piggy-BaLk Award and this Agreement to be binding upun Vendur. Vendor further agrees that
hat no interlineaticins ur
changes to this Agreement by Vendur will be binding on National Wuperative, unless such changes are agreed to by its
BuyBudi d Administi dtui in writing.
3. Vendur agrees that it shall uffer its goods and Sel"ViLeS to National Cuciperative members at the same unit pricing and
same general terms and cunditions, Subject to applicable State laws in the state Uf purchase, as tequited by the Underlying
Award. Huwever, nothing in this Agreement prevents Vendur from, uffering Natiunal Cucipetative members better (i.e., luwel)
CUMpetitiVe pricing and more fdvurable terms and LUnditicins than those in the Underlying Award.
4. Vendur hereby agrees and LUf1fh'MS that it will Serve those states it has designated u" the State Set Vice Designation Form
of this Prupusal invitation. Any changes to the states designated un the State Sel'ViLe Designation Furor must be appruved
in wilting by the buyBuard Administrator.
5. Vendur agrees to pay National CuuperatiVe the Sel'ViLe tee provided fur in the Underlying Award based on the amount ut
purchases generated frum National Wuperative members through the Piggy -back Award. Vendur shall remit payment to
National Lucipetative on such Schedule as it Specifies (which shall not be mote often than monthly). Further, upon tecluest,
Vendur shall piuvide National Lucliperative with WpieS Uf all purchase urders generated hum, National Wuperative members,
vendur if]VUiLeS, and/ur such uther documentation regarding those purchase urdet's as the Cuciperdtive's administraturs may
require in their reasunable diSlLretiun fur purpuses of reviewing and verifying pUithase activity. Vendur further agrees that
Natiunal Wuperative shall have the right, upon reasunable written notice, to review Vendur's recut ds pertaining to purchases
made by National Cuciperative members in under to verify the aLLW'dLy of Sel-ViLe fees.
6. Vendur agrees that the Underlying Award, including its General Terms and Cunditicins, are adopted by reference to the
fullest extent Such PIUViSiU"S can 1'eaSUnably apply to the PUSt-PIL11PUSal/iLL!"tiaLt award phase. The tights and respunsibilities
that would ut-di"arily inure to the'rexas Cuciperative pursuant to the Underlying Award shall inure to Natiunal Cuciperative,
arid, conversely, the tights and tespunsibilities that would urdinatily inuie to Vendur in the Underlying Award shall inute to
Vendur in this Agreement. Vendur teLUgnizes and agrees that Vendur and National Lucipetative ate the only patties to this
Agreement, and that nothing in this Agreement has application to uthei, thii'd patties, including the Texas Cuciperative. in the
event Uf conflict between this Agreement and the terms ut the Underlying Award, the terms of this Agreement Shall LUntlol,
and then only to the extent neWSSdly to feWfldle the conflict.
Proposal Forms C.JMWSvLS v.08.11.2021
Page 31 Ur A
Board'
,1tvuacxasixc cooxxAnrc
12007 Research Boulevard' Austin, Texas 78759-2439 - PH: 800-695-2919 - buvboard.com
7. This Agreement shall be governed and construed In accordance with the laws of the State of Rhode Island and venue for
any dispute shall lie In the federal district court of Alexandria, Virginia.
8. Vendor acknowledges and agrees that the award of a Piggy -Back Award Is within the sole discretion of National
Cooperative, and that this Agreement does not take effect unless and until National Cooperative awards Vendor a Piggy -Back
Award and the BuyBoard Administrator notifies Vendor in writing of such Piggy -Back Award as provided for herein.
WHEREFORE, by signing below Vendor agrees to the foregoing and warrants that it has the authority to enter into this
Agreement.
Pe "ante HeeMh Suppb LLC , DBA Metl Supply Cvnpa 704-23
Name of Vendor Proposal Invitation Number
cftl;� a/dz� Stephen Weiss
Signa urt a of Authorized Company Official Printed Name of Authorized Company Official
1 /23/2023
Date
Pg iFq s COMM/5VC5 vM 11 n2l
Page 32 of 71
Board
PYRCNISINC COOPPRIr1VE
12007 Research Boulevard' Austin, Texas 78759-2439 - PH: 800-695-2919 - huvboard.com
LOCATION/AUTHORIZED SELLER LISTINGS
If you have more than one location/authorized seller that will service a Contract awarded under this Proposal Invitation,
please list each location/authorized seller below. If additional sheets are required, please duplicate this form as necessary.
NOTE: Awarded Vendors shall remain responsible for all aspects of the Contract, including processing of Purchase Orders,
and shall be responsible for the performance of all locations and authorized sellers under and in accordance with the Contract.
Tfyou are a product manufacturer and wish to designate Designated Dealers as deflined in the Genera/ Terms
and Conditions to receive Cooperative member Purchase Orders on your behalf, you must complete the
Manufacturer Designated Dealer form.
N/A N/A N/A
Page 33d]1 P0R lFO s camm�ucs Vw 11 ion
WW
Board
URrhASiNG C&OPERATWE
12UU? Research Buulevard I Austin `Texas ?8?59-2439 - Hh: 8UU-695-2919 I buybuarcl.cum
MANUFACTURER DEALER DESIGNATION
if Vendur is a manufactuiet that sells piuductsthiulugh a dealer netwuik and wishes to designate a dealerur multiple dealers
("Designated Dealers") to receive Cuuperative member Purchase Ordevs un Vendur's behalf, yuu must complete this fui'm full,
each dealer yuu wish to designate.
Regardless of any Designated Dealers submitted by Vendur, Vendur specifically agrees and ackriuwledges that any such
designatiunS are fur Vendur's cunvenience unly and shall nut, it Vendur is awarded a Contract, relieve Vendur of any
ubligatiuns under the Cunti-act, including payment of Cuuperative service fees un all Purchase Ovdevs submitted to Vendor uv
any Designated Dealer. in accui-dance with the General 'I evnis and Cunditiuns, an awarded Vendor shall remain vespunsible
and liable fui- all of its ubligatiuns under the Cunti-act and the pei tui manse of buth Vendur and any of Venduvs Designated
Dealers under and in accui dance with the Cunti-act and remain subject to all remedies fur default thereunder, including, but
nut limited to suspensiun and tei-miriatiun of Venduv's Cuntvact fur nunpayment of service fees.
it awarded, Vendui authudzes the CUL11peidtive, in its sule disci-etiun, to list any Vendur Designated Dealers in the BuyBuaid
system, and to receive Purchase Orders directly fi-um Cuuperative members un behalf of Venduv.fu the extent a Vendur with
Designated Dealers ieceives a Purchase Order directly, it shall be the iespunsibility of Vendur to appiupdately process such
Purchase Di-dev in accordance with the Cunbact, including but nut limited to timely fuiwaiding such Purchase Order to a
Designated Dealer fur pi-cicessing.
'The Cuuperative reserves the light, in its rule discretiun, to refuse additiun ut, ut request removal ut, any Designated Dealer,
and Vendur agrees to immediately require such Designated Dealer to Cease accepting Purchase Orders uv utheiwise acting
un Vendcli's behalf under the CuntiaLt. Fuithei, the Cuuperative administiatur shall be authorized to remove ur suspend any
ut all Desigliuted Dedlei S hurn the Buybudid at aiq time hi its scale dis,Uetiuii.
if yuu wish to designate a dealer to service a LU11l1ldLt awarded under this Prupusal invitatiun, please list the Designated
Dealet beluw. if yuu wish to designate multiple dealers, please duplicate this fut in as necessary.
N/A - Not Applicable
Designated Dealet Name
N/A
Designated Dealer Address
N/A N/A
City State
-N/A
Phune Number
N/A
Email address
NiA
Designated Dealer Luntact Persun
N/A
Zip
N/A
Fax Number
N/A
Designated Dealer'fax 1D Numbe, -- (attach W-9)
Page 34 ut A
Proposal Forms LJMWSvLS v.08.11.2021
Board
PYRCNISINC COOPPRIr1VE
12007 Research Boulevard' Austin, Texas 78759-2439. PH: 800-695-2919' buvboard.com
PROPOSAL INVITATION QUESTIONNAIRE
The Cooperative will use your responses to the questions below in evaluating your Proposal and technical and financial
resources to provide the goods and perform the services ("Work'0 under the BuyBoard contract contemplated by this Proposal
Invitation ("Contract'o. Proposers must fully answer each question, numbering your responses to correspond to the
questions/numbers below. Proposers must complete below or attach your responses to this questionnaire and submit in one
document with your Proposal. You must submit the questionnaire and responses with your Proposal or the
Proposal will not be considered.
1. List the number of years Proposer has been In business and former business names (if applicable). Note whether your
company is currently for sale or involved in any transaction that would significantly alter its business or result in acquisition
by another entity.
67 Years. 6 Years under the name Performance Health. Previous name was Patterson Medical.
2. Describe the resources Proposer has to manage staff and successfully perform the Work contemplated under this
Contract. State the number and summarize the experience of company personnel who may be utilized for the Work,
including those who will be available to Cooperative members for assistance with project development, technical issues,
and product selection for Work associated with this Contract.
The main contact for this contract will be Stephen Weiss. He will monitor and update any information
on the BuyBoard Portal/Page. Stephen will be responsible for giving customers Quotes that will reflect
the BuyBoard discount and then the Medco order entry team will be responsible for placing the orders
after we receive the PO's from the BuyBoard portal or from the customer directly.
3. Markatino Stra": For your Proposal to be considered, you must submit the Marketing Strategy you will use if the
Cooperative accepts al or part of your Proposal. (Examn/a. Explain how your company will initiallyinfann Cooperative
members ofy ourBuySaard Co tra andhow yaw will continue to suppoitMe BuyBoard for Me dwaton of Me Contract
term.)Attach additional pages if necessary.
We will be putting the BuyBoard number on the Quote to reflect the discount so customers can utilize this contract and
we will also talk about this contract with in person visits utlilizing our outside sales reps as well as having conversations
over the phone or via email so customers can avoid the bidding process and order from our company in the end.
Page 35d]1 P'0R iFO s COMMnucs Vw 11 ion
WW
Board
URrhASiNG C&OPERATWE
MW Research Buulevard I Austin, exas /8/59-2439 - Hh: 8UU-695-2919 I buybuard.curn
4. Describe Prupusei"s financial capability to perturm, the Cuntract. State ur describe the firm's financial strength and rating,
bunding capacity, and insurance coverage limits. State whether the firm, ur any of the firm's past ur present owners,
principal shatehulders ur 5-tuckhulders, ur ulticeis, have been a debtor party to a bankruptcy, receivership, ur insolvency
proceeding in the last / years, and identify any such debtor' party by name and relatiunship to or pusitiun with your firm.
We have the financial capability for performing this contract and paying our monthly invoices on time.
We will be piumoting this cuntraut to the best of uur ability su we can increase uur sales year after year, and to make sure
uui custumeis take advantage of this discount to help di ivebsales tui us arid to strengthen our ielatiunship with BuySuard.
We don't ridvra any uwnrais, shdiunulduis, ui stuukhulduis that have Ueeii d debtor party to d Udiikiuptuy, iuUUivuiship,
of kirsulvericy piuceeding in the last 7 years.
S. UUUS YUUV company have any uutstanding financial judgments and/ur- is it currently in default un any loan ur financing
agreement? it su, provide detailed infur-matiun un the nature of Such items and prospects fur- resolution.
No. N/A
6. List all WntfdlUS, it any, in the last IU year's un which Kupuser, has defaulted, failed to complete ur, deliver, the wurk, ur
that have been terminated for any r'easun. Fur each Such LuntraLt, pruvide the pr-uject name, scope, value and date and
the name of the PIULUI iHg entity. Fully explain the JILUMStdiroes of the default, failui e to complete or dulivei the v'rui k,
ur, ter,minatiun.
None. NA
7. List all litigatiun or other legal PIULeedings (including arbitration pruceedings), it any, in the last 10 years bluught against
yuut film, ur any of the firm's past ur present uwners, principal shareholders ur stuckhuldets, officers, agents or
empluyees, that relate to or arise from a WntfalLt similar, to this CuntfaLt ur, the Work contemplated under, this CuntraLt.
Pruvide the style of the lawsuit Ui' proceeding (name of parties and LUUlt ui, tribunal in which tiled), nature of the claim,
and VeSUIUdUn UI'current status.
Nuns. N/A
Proposal Forms C.OMWSvLS v.08.11.2021
Page 3U of /i
Board
PYRCNISINC COOPPRIr1VE
12007 Research Boulevard' Austin, Texas 78759-2439 - PH: 800-695-2919 - huvboard.com
VENDOR REQUEST TO SELF -REPORT BUYBOARD PURCHASES
The General Terms and Conditions require that all Purchase Orders generated by or under any Contract awarded under this
Proposal Invitation be processed through the BuyBoard and, except as expressly authorized in writing by the Cooperative
administrator, Vendors are not authorized to process Purchase Orders received directly from Cooperative members that have
not been processed through the BuyBoard or provided to the Cooperative. In accordance with this provision, Vendor may
request authorization of the Cooperative administrator to self -report Cooperative member purchases if awarded a Contract
under this Proposal Invitation. By making such a request, Vendor acknowledges and agrees that self -reporting is specifically
subject to and conditioned upon (1) Vendor's agreement to the Additional Terms and Conditions for BuyBoard Self-Repordng
which are incuded in this Proposal Invitation and incorporated herein for all purposes and (2) approval of this request in
wridng by the Cooperative administrator.
Note. ThisformisNOTrequiredaspartofyourproposal. You should sign and return this form ONL Yifyou
wish to request authorization to self -report BuyBoard purchases. Any request to self -report will not be effective,
and Vendor shall not be authorized to self -report BuyBoard member purchases, unless and until (1) Vendor is awarded a
Contract under this Proposal Invitation, and (2) the request has been approved In writing by the Cooperative administrator.
By my signature below, I hereby request authorization from the Cooperative administrator to self -report
BuyBoard purchaser ifmy company isawarded a Contract. Icertify that Iam authorized by the above -named
Vendor to approve this form, and I have received and read the Additional Terms and Conditions farBuyeoard
Self -Reporting included in this Proposal Invitation and do hereby approve and agree to such terms and
conditions on behalf of Vendor.
Performance Health Supply LLC, DBA Medco Supply Company
NAME Of�F�7V�E�N� VENDOR:
Signa� of Vendor A� ri� presentative
Printed Name: Stephen Weiss
title: Sales Support Coordinator
Date: 1 /23/2023
(For Cooperative Administrator Use Onil)
Approved by BuyBoard Administrator:
Effective/Start Date for Self -Reporting:
Page 3]d]1 P'0R iFO s COMMnucs vw 11 ion
Board
PYRCNISINC COOPPRIr1VE
12007 Research Boulevard' Austin, Texas 78759-2439 - PH: 800-695-2919' buvboardxom
REOUIRED FORMS CHECKLIST
(%ease check (�o the following)
0 Reviewed/Completed: Proposer's Acceptance and Agreement
PROPOSAL FORMS PART I: COMPLTANCE FORMS
Reviewed/Completed: Proposal Acknowledgements
Reviewed/COmDleted: Felony Conviction Disclosure
Reviewed/Completed: Resident/Nonresident Certification
Reviewed/Completed: Debarment Certification
Reviewed/Completed:
Vendor Employment Certification
Reviewed/Completed:
No Boycott Verification
Reviewed/Completed:
No Excluded Nation or Foreign Terrorist Organization Certification
Reviewed/Completed:
Historically Underutilized Business Certification
Reviewed/Completed:
Acknowledgement of BuyBoard Technical Requirements
Reviewed/ anndeted:
Construction -Related Goods and Services Affirmation
Reviewed/Completed: Deviation and Compliance
Reviewed/Completed: Vendor Consent for Name Brand Use
Reviewed/CmmnipW- Confidential/Proprietary Information
Reviewed/Cnmnleted: EDGAR Vendor Certification
Reviewed/Completed: Compliance Forms Signature Page
PROPOSAL FORMS PART I: VENDOR INMRMATInN FnRMS
Reviewed/CmmnlPfM•
Vendor Business Name
Reviewed/(hmnI&Pd:
Vendor Contact Information (romp/etern ekrhpnkrcpvposa/svtmavmsystan)
Reviewed/Completed:
Federal and State/Purchasing Cooperative Experience
Reviewed/Completed:
Governmental References
Reviewed/Completed:
Company Profile
Reviewed/Completed:
Texas Regional Service Designation(mmp/etemekdmnicproposa/submmmsysicvn)
Reviewed/Completed:
State Service Designation (co p/etemekxtmnicpmposawwbmrssronsWa )
Reviewed/Completed:
National Purchasing Cooperative VendorAward Agreement (uazkvssawngouame 7easmy)
Reviewed/Completed:
Local/Authorized Seller Listings
Reviewed/CmmnWP 1-
Manufacturer Dealer Designation
Reviewed/CnmoIPtM:
Proposal Invitation Questionnaire
Reviewed/Completed:
Vendor Request to Self -Report BuyBoard Purchases (Opbma9
0 Reviewed/Completed: Proposal Specifications Discount (o)off Cata/og/PrkWistand/or other requiredpncing
information indudmg Catalogs/Pnrelists (or no bid response) must be submitted witll the Proposal or the Proposal W11not
be considered.
Page 39d]1 Pm+osal F° s COMMnucs Vw 11 n2l
Board
PYRCNISINC COOPERIr1VE
12007 Research Boulevard' Austin, Texas 78759-2439 - PH: 800-695-2919 - buvboard.com
PROPOSAL SPECIFICATION SUMMARY
The categories and items specified for this Proposal Invitation are summarized below. For full Proposal
Specifications, you must review and complete the Proposal Specification information in the electronic proposal
submission system in accordance with the Instructions to Proposers (or, if submitting a hard copy Proposal, timely
request and complete the Proposal Specification Form in accordance with the Instructions to Proposers).
PR9POSAL NgTF: Vendors shall submit catalog(s)/pricelist(s) with their Proposal response or the Proposal will not be
consdered. Vendors shall submit catalog(s)/pricelist(s) with the Proposal in a rea Illy available and readable electronic format,
with Excel or searchable PDF preferred. No pacer catalogs or manufacturer rvendor websibe will he accented.
Section I: First Aid Equit Products. and Supplies
1. Discount (%) off catalog/pricelist for First Aid Equipment and Supplies.
2. Discount (%) off catalog/pncellst for First Aid Furniture.
3. Discount (%) off catalog/pncelist for Bleeding Control Stations.
4. Discount (%) off catalog/pricelist for All Other First Aid, Health, and Nursing Products.
Section II: Athletic Trainer/Rehabiligquipme t.products. and Suoolies
5. Discount %off cetteprc�ramerReabilitation Equipment and Supplies.
6. Discount (%) off catalog/pricelist for Athletic Trainer/Rehabilitation Furniture.
7. Discount (%) off catalog/pricelist for All Other Athletic Trainer/Rehabilitation Products.
Section III: �menry t�dipal Fguioment Prq[fu(fs. And 5ugg@
8. Discount (°/ o catallog/price t for Emergency a rca Equipment and Supplies
9. Discount (%) off catalog/pdcelist for All Other Emergency Medical Products.
Sectirm IV: Pharmaceuticals and Vaccines
10. Discount (%) off catalog/pricelist for Pharmaceuticals and Vaccines.
11. Discount (%) off catalog/pricellst for Intra-Venous Pharmaceutical Supplies.
12. Discount (%) off catalog/prlcellst for Drug Testing Kts and Supplies.
amipt ,ia Related Items
13. Discount (%) off catalog/price) st r u ro ogy Equipment, Hearing Aids, and Other Related Items.
Section VI! Druo/Diagnostic/L horatory Testing ServY_es
14. Discount (%) off catalog/pricelist for Drug and Alcohol Diagnostic Testing Services (onsite and offsite including
laboratory services).
,Section VII: Installatipnand jr-Rgpmice
15. Hourly Labor Rate for Installation/Repair Service of First Aid, Athletic Trainer/Rehabilitation, and
Emergency Medical Equipment and Products - Not to Exceed hourly labor rate for Installation/Repair Service of
Equipment and Products.
16. Hourly Labor Rate for Installation/Repair of Audiology Equipment and Products - Not to Exceed hourly labor
rate for Installation/Repair Service of Equipment and Products.
Pg iFq s COMM/5VC5 vW 11 n2l
Page 38 of 7t
Medco Supply Company Information
Contact:
Stephen Weiss
Address:
28100 Torch Parkway
Suite 800
Warrenville, IL60555
Phone:
(800)556-3326
Fax.
(800)222-1934
Email
medcosalessupport@medcosupply.00m dd
Web Address. www medco-athletics.com
By submitting your response, you certify that you are authorized to represent and bind your company.
Stephen Weiss medr�salessuoport(7a.medcosupplv.cem
signature Ema!
Submitted at 1/2872023 10:18:05 AM (CT)
Requested Attachments
Exceptions and/or Detailed Information Related to Discount % Catalog Discount Sheet - BuyBoard.pdf
and/or Hourly Labor Rate Proposed
In PDF format and if necessary, vendor shall attach detailed information regarding exceptions to pricing and/or
discount percentage and define the services that are proposed to be provided. NOTE IF DETAILED INFORMATION IS
NOT SUBMITTED, PROPOSAL MAY NOT BE CONSIDERED. (Please DO NOT password protect uploaded files.)
BuyBoard Proposal Invitation No. 704-23 First Aid, Emergency BuyBoard Proposal-No-704-23.pdf
Medical, and Athletic Trainer Supplies and Equipment
REQUIRED -In PDF format, upload all proposal invitation documents available for download at vendor.buyboard.mm
including any additional pages, as necessary. NOTICE: DO NOT complete proposal forms in internet browser. No data
will be stored. Download file to computer and complete proposal forms prior to submitting. (Please DO NOT password
protect uploaded files.)
Catalog/Pricelist Buy Board Items 2023.xlsx
REQUIRED -In Excel or PDF format, upload catalog(s)/pricelist(s) in accordance with proposal invitation instructions.
Vendors shall submit catalog(sypricelist(s) with their Proposal response or Proposal will not be considered. No paper
catalogs or manufacturer/vendor websites will be accepted. File size must not exceed 250MB. (Please DO NOT
password protect uploaded files.)
Company Profile Medco Sports Medicine - Company Profile.pdf
REQUIRED -Information on awarded Cooperative Contracts is available to Cooperative Members on the BuyBoard
website. If your company is awarded a Contract under this Proposal Invitation, please provide a brief company
description that you would like to have included with your company profile on the BuyBoard website. Submit your
company profile in a separate file, in Word format, with your Proposal. (Note: Vendor is solely responsible for any
content provided for inclusion on the BuyBoard website. The Cooperative reserves the right to exclude or remove any
content in its sole discretion, with or without prior notice, including but not limited to any content deemed by the
Cooperative to be inappropriate, irrelevant to the Contract, inaccurate, or misleading.)
IRS Form W-9 Request for Taxpayer Identification Number and Certification W-9 Form.pdf
REQUIRED -In PDF format, upload W-9 form. (Please DO NOT password protect uploaded files.)
Response Attachments
ESTMD3084791.pdf
QUOTE/CONTRACT
Page 3 or 31 pages Vendor Medoo Supply Company 704-23
Certifi cate_of_Liabi lity. pdf
INSURANCE CERTIFICATE
Medco Sports Medicine Logo - Blue.png
MEDCO SPORTS MEDICINE LOGO
Catalog Discount Sheet- BuyBoard.pdf
FORM THAT BREAKS DOWN THE 0-25 % OFF CATALOG DISCOUNT
Bid Attributes
1 Federal Identification Number
Federal Identification Number
136-4391091
2 HUB/No Israel Boycott Certification/No Excluded Nation or Foreign Terrorist Certification
HUB/No Israel Boycott Certification/No Excluded Nation or Foreign Terrorist Certification
3 No Israel Boycott Certification
A Texas governmental entity may not enter into a contract with a value of $100,000 or more that is to be paid wholly
or partly from public funds with a company (excluding a sole proprietorship) that has 10 or more full-time employees
for goods or services unless the contract Contains a written verification from the company that It: (1) does not
boycott Israel; and (2) will not boycott Israel during the term of the Contract. (TEX. GOV'T CODE Ch. 2270).
Accordingly, this certification form is Included to the extent required by law.
"Boycott Israel" means refusing to deal with, terminating business activi0es with, or otherwise taking any action that
is intended to penalize, inflict economic harm on, or limit commercial relations specifically with Israel, or with a
person or entity doing business in Israel or in an Israeli -controlled territory, but does not include an action made for
ordinary business purposes. TEX. GOV'T CODE §808.001(1).
By signature on the Compliance Forms Signature Page, to the extent applicable, I certify and verify that Vendor
does not boycott Israel and will not boycott Israel during the term of any contract awarded under this Proposal
Invitation, that this certification is true, complete and accurate, and that I am authorized by my company to make this
certification.
Yes
4 No Excluded Nation or Foreign Terrorist Organization Certification
Chapter 2252 of the Texas Government Code provides that a Texas governmental entity may not enter Into a
contract with a company engaged In active business operations with Sudan, Iran, or a foreign terrorist organization
— specifically, any company Identified on a list prepared and maintained by the Texas Comptroller under Texas
Government Code §1806.051, 807.051, or 2252.153. (A company that the U.S. Government affirmatively declares
to be excluded from Its federal sanctions regime relating to Sudan, Iran, or any federal sanctions regime relating to
a foreign terrorist organization is not subject to the contract prohibition.)
By signature on the Compliance Forms Signature Page, I certify and verify that Vendor is not on the Texas
Comptroller's list identified above; that this certification is true, complete and accurate; and that I am authorized by
my company to make this certification.
Yes
Page 4 of 31 pages Vendor Medico Supply Company 704-23
5
MWBE/HUB Status Certification
A Proposer that has been certified as a Historically Underutilized Business (also known as a Minority/Women
Business Enterprise or "MWBE" and all referred to in this form as a "HUB") is encouraged to indicate its HUB
certification status when responding to this Proposal Invitation. The BuyBoard website will indicate HUB certifications
for awarded Vendors that properly indicate and document their HUB certification on this form.
I certify that my company has been certified as a MWBEIHUB in the following categories: (Please check all that
apply)
6 Minority Owned Business
Minority Owned Business
❑ Minority Owned Business (Yes)
T 1 Women awned Business
0
Women Owned Business
❑ Women Owned Business (Yes)
Service -Disabled Veteran Owned Business
Service -Disabled Veteran Owned Business (veteran defined by 38 U.S.C. §101(2), who has a service -connected
disability as defined by 38 U.S.C. § 101(16), and who has a disability rating of 20% or more as determined by the U.
S. Department of Veterans Affairs or Department of Defense)
❑ Service -Disabled Veteran Owned Business (Yes)
9 Certification Number
Certification Number
NIA
1 Name of Certifying Agency
0 Certifying Agency
NIA
1 Non-MWBEIHUB
1 My company has NOT been certified as a MWBE/HUB
7 Non -HUB (Yes)
2 I Vendor General Contact Information
Proposal/Contract General Contact Information
1 I Vendor Proposal/Contract Contact Name
3 Vendor Proposal/Contract Contact Name
Stephen Weiss
1 Vendor Proposal/Contract Contact E-mail Address
4 Vendor Proposal/Contract Contact E-mail Address
Medcosalessupport@medcosupply.com
1 I Vendor Proposal/Contract Mailing Address
5 Vendor Proposal/Contract Mailing Address
21800 Torch Parkway, Suite 800
F 1 v a of j i Fa. v.> V' . idur: Nkadu=j :3upply . u tN_, sy 7u4
1 I Vendor Proposal/Contact Mailing Address - City
B Vendor Proposal/Contact Mailing Address - City
Warrenville
1 Vendor Proposal/Contact Mailing Address - State
T Vendor Proposal/Contact Mailing Address - State (Abbreviate state Name)
IL
1 Vendor Proposal/Contact Mailing Address - Zip Code
8 Vendor Proposal/Contact Mailing Address - Zip Code
160555
1 Vendor Proposal/Contact Phone Number
9 Vendor Proposal/Contact Phone Number (xxx-x«)o=)
1800-556-3326
2 Vendor Proposal/Contact Extension Number
0 Vendor Proposal/Contact Extension Number
No response
9 I Company Website
Company Website (www.xxxxx.com)
2
2
Purchase Orders Contact Information
All Purchase Orders from Cooperative members will be available through the Internet. Vendors need Internet
access and at least one e-mail address so that notification of new orders can be sent to the Internet contact when a
new purchase order arrives. An information guide will be provided to Vendors to assist them with retrieving their
orders.
Please select options below for receipt of Purchase Orders and provide the requested information:
• I will use the internet to receive Purchase Orders at the following address
I Yes
2 I Purchase Order E-mail Address
Purchase Order E-mail Address
Medcosalessupport@medcosupply.com
2 I Purchase Order Contact Name
Purchase Order Contact Name
Stephen Weiss
2 I Purchase Order Contact Phone Number
5 Purchase Order Contact Phone Number (xxx-xx =a)
800-556-3326
F 1 v �j of j i r' '-ts* . v'_.si:ur: ;supply sy 7.:4
2 I Purchase Order Contact Extension Number
6 Purchase Order Contact Extension Number
No response
2 � Alternate Purchase Order E-mail Address
7 Alternate Purchase Order E-mail Address
No response
2 I Alternate Purchase Order Contact Name
8 Alternate Purchase Order Contact Name
No response
2 I Alternate Purchase Order Contact Phone Number
9 I` Alternate Purchase Order Contact Phone Number (xxx-xxx-xxxx)
No response
3 � Alternate Purchase Order Contact Extension Number
U Alternate Purchase Order Contact Extension Number
3
1
No response
Purchase Orders Contact Information
All Purchase Orders from Cooperative members will be available through the Internet. Vendors need Internet
access and at least one e-mail address so that notification of new orders can be sent to the Internet contact when a
new purchase order arrives. An information guide will be provided to Vendors to assist them with retrieving their
orders.
Please select options below for receipt of Purchase Orders and provide the requested information:
• Purchase Orders may be received by the Designated Dealer(s) identified on my company's Dealer
Designation form as provided to the Cooperative administrator. I understand that my company shall remain
responsible for the Contract and the performance of all Designated Dealers under and in accordance with
the Contract.
IYes
3 I Request for Quotes (RFQ)
2 Cooperative members will send RFQs to you by e-mail. Please provide e-mail addresses for the receipt of RFQs:
3 I Request for Quote (RFQ) E-mail Address
3 Request for Quote (RFQ) E-mail Address
Medcosalessupport@medcosupply.com
3 Request for Quote (RFQ) Contact Name
4 Request for Quote (RFQ) Contact Name
Stephen Weiss
3 Request for Quote (RFQ) Contact Phone Number
5 Request for Quote (RFQ) Contact Phone Number (xo«-xxx-)coot)
1800-556-3326
rage I of 31 pageS Vendur: Meduu Supply Gumpany1 704-23
3 I Request for Quote (RFQ) Contact Extension Number
6 Request for Quote (RFQ) Contact Extension Number
No response
3 I Alternate Request for Quote (RFQ) E-mail Address
7 Alternate Request for Quote (RFQ) E-mail Address,
No response
3 Alternate Request for Quote (RFQ) Contact Name
S Alternate Request for Quote (RFQ) Contact Name
No response
3 Alternate Request for Quote {RFQ} Contact Phone Number
9 Alternate Request for Quote (RFQ) Contact Phone Number (xxx-xxx-xxxx)
No response
4 I Alternate Request for Quote (RFQ) Contact Extension Number
U Alternate Request for Quote (RFQ) Contact Extension Number
4
1
4
2
No response
I invoices
Your company will be billed monthly for the service fee due under a Contract awarded under this Proposal
Invitation. All invoices are available on the BuyBoard website and e-mail notifications will be sent when
they are ready to be retrieved.
I invoices
Please choose only one (1 ) of the following options for receipt of invoices and provide the requested
information:
(a) Service fee invoices and related communications should be provided directly to my company at:
or
(b) In lieu of my company, I request and authorize all service fee invoices to be provided directly to the following
billing agent:
If Vendor authorizes a billing agent to receive and process service fee invoices, in accordance with the General Terms and Conditions of the Contract,
Vendor specifically acknowledges and agrees that nothing in that designation shalt relieve Vendor of its responsibilities and obligations under the
Contract including, but not limited to, payment of all service fees under any Contract awarded Vendor.
Service fee invoices and notices direct to company
4 � Invoice Company Name
3 Invoice Company Name
Performance Health Supply LLC , DBA Medco Supply Company
4 Invoice Company Department Name
4 Invoice Company Department Name
Sales Support Department
Page 8 of 3 1 pages Vendur: Medcu Supply Cumpany1 704-23
4 Invoice Contact Name
5 Invoice Contact Name
Stephen Weiss
4 Invoice Mailing Address
5 Invoice Mailing Address (P.O. Box or Street Address)
128100 Torch Parkway, SORB 800
4 Invoice Mailing Address - City
7 Invoice Mailing Address - City
Warrenvllle
4 Invoice Mailing Address - State
B Invoice Mailing Address - State (Abbreviate State Name)
J IL
4 Invoice Mailing Address - Zip Code
9 Invoice Mailing Address (Zip Code)
160555
5 Invoice Contact Phone Number
g Invoice Contact Phone Number (xxz-xxx-xxxx)
1800-556-3326
5 Invoice Contact Extension Number
Invoice Contact Extension Number
INo response
5 Invoice Contact Fax Number
Z Invoice Contact Fax Number (xxx-xxx-xxxx)
1800-222-1934
5 Invoice Contact E-mail Address
3 Invoice Contact E-mail
Medcosalessuppon@medcosupply.com
5 Invoice Contact Alternate E-mail Address
4 Invoice Contact Alternate E-mail Address
I No response
5 Billing Agent Company Name
5 Billing Agent Company Name
I No response
5 Billing Agent Department Name
5 Billing Agent Department Name
INo response
Page 9 of 31 pages Vendor Medco Supply Company 704-23
5 Billing Agent Contact Name
7 Billing Agent Contact Name
No response
5 Billing Agent Mailing Address
Billing Agent Mailing Address (P.O. Box or Street Address)
No response
5 Billing Agent Mailing Address - City
Billing Agent Mailing Address - City
No response
6 Billing Agent Mailing Address - State
Billing Agent Mailing Address - State (Abbreviate State Name)
No response
1 Billing Agent Mailing Address - Zip Code
Billing Agent Mailing Address - Zip Code
No response
6 Billing Agent Contact Phone Number
Billing Agent Contact Phone Number (xxx-xxx-xxxx)
No response
6 Billing Agent Contact Extension Number
Billing Agent Contact Extension Number
No response
6 Billing Agent Fax Number
Billing Agent Fax Number
No response
6 Billing Agent Contact E-mail Address
5 Billing Agent Contact E-mail Address
No response
6Billing Agent Alternative E-mail Address
6
Billing Agent Alternative E-mail Address
No response
6 I Shipping Via
7 Common Carrier, Company Truck, Prepaid and Add to Invoice, or Other
Common Carrier!
I'aye i U of .3 1 pcluetm
Vviidur: Medw Supply Currtpar'Y' 7U4-23
6 Payment Terms
8 Note: Vendor payment terms must comply with the BuyBoard General Terms and Conditions and the Texas Prompt
Payment Act (Texas Government Corte Ch. 2251).
Net 30
6 Vendor's Internal/Assigned Reference/Quote Number
9 Vendor's Internal/Assigned Reference/Quote Number
ESTMD3084791
7 State or Attach Return Policy
U Note: Only return requirements and processes will be deemed part of Vendor's return policy. Any unrelated contract
terms, terms of sale, or other information not specifically related to return requirements and processes included in
Vendor's return policy shall not apply to any awarded Contract unless specifically included as a deviation in the
Deviation and Compliance Form and accepted by the Cooperative.
Please email medcocustomerservice@medcosupply.com or call them at 800-556-3326 to process a return. No
returns will be accepted after 90 days.
7 Electronic Payments
1 Are electronic payments acceptable to your company?
IYes 1
7 Credit Card Payments
2 Are credit card payments acceptable to your company?
Yes
7
3
Texas Regional Service Designation
Texas Regional Service Designation - Refer to Form in Proposal Invitation
The Cooperative (referred to as "Texas Cooperative" in this form and in the State Service Designation form) offers
vendors the opportunity to service its members throughout the entire State of Texas. If you do not plan to service all
Texas Cooperative members statewide, you must indicate the specific regions you will service on this form. If you
propose to serve different regions for different products or services included in your Proposal, you must complete
and submit a separate Texas Regional Service Designation form for each group of products and clearly indicate the
products or services to which the designation applies. By designating a region or regions, you are certifying that
you are authorized and willing to provide the proposed products and services in those regions. Designating
regions in which you are either unable or unwilling to provide the specified products and services shall be
grounds for either rejection of your Proposal or, if awarded, termination of your Contract. Additionally, if you
do not plan to service Texas Cooperative members (i.e., if you will service only states other than Texas), you must
so indicate on this form.
7 Company Name
4 Company Name
I Performance Health Supply LLC
7 Texas Regional Service Designation
5 Select only one of the following options. If you select "I will NOT serve all Regions of Texas", you must then
check the individual Regions you wish to serve.
All Regions
page 11 of 31 pages Vendur: Meduu Supply Cumpany1 704-23
7 Region 1
6 Region 1 - Edinburg
❑ Region 1 (1)
7 Region 2
7 Region 2 - Corpus Christi
❑ Region 2 (2)
7 Region 3
8 Region 3 -Victoria
❑ Region 3 (3)
7 Region 4
9 Region 4 - Houston
❑ Region 4 (4)
8 Region 5
0 Region 5 - Beaumont
❑ Region 5 (5)
8 Region 6
1 Region 6 - Huntsville
❑ Region 6 (6)
8 Region 7
2 Region 7 - Kilgore
❑ Region 7 (7)
8 Region 8
3 Region 8 - Mount Pleasant
❑ Region 8 (6)
8 Region 9
4 Region 9 -Wichita Falls
❑ Region 9 (9)
8 Region 10
5 Region 10 - Richardson
❑ Region 10 (10)
8 Region 11
6 Region 11 - Fort Worth
❑ Region 11 (11)
8 Region 12
7 Region 12 - Waco
❑ Region 12 (12)
Page 12 of 31 pages Vendor Medoo Supply Company 704-23
8 Region 13
Region 13 - Austin
❑ Region 13 (13)
8 Region 14 g
Region 14 - Abilene
❑ Region 14 (14)
9 Region 15
0 Region 15 - San Angelo
❑ Region 15 (15)
1 Region 16
Region 16 - Amarillo
❑ Region 16 (16)
9 Region 17
2 Region 17 - Lubbock
❑ Region 17 (17)
9 Region 18
Region 18 - Midland
❑ Region 18 (18)
99 Region 19
Region 19 - El Paso
❑ Region 19 (19)
9 Region 20
5 Region 20 - San Antonio
❑ Region 20 (20)
9
6
State Service Designation
State Service Designation - Refer to Form in Proposal Invitation.
As set forth in the Proposal Invitation, it is the Cooperative's intent that other governmental entities in the United
States have the opportunity to purchase goods or services awarded under the Contract, subject to applicable state
law, through a piggy -back award or similar agreement through the National Purchasing Cooperative BuyBoard. If
you plan to service the entire United States or only specific states, you must complete this form accordingly. {Note:
If you plan to service Texas Cooperative members, be sure that you complete the Texas Regional Service
Designation farm.} In addition to this form, to be considered for a piggy -back award by the National
Purchasing Cooperative, you must have an authorized representative sign the National Purchasing
Cooperative Vendor Award Agreement that follows this form.
If you serve different states for different products or services included in your Proposal, you must complete and
submit a separate State Service Designation form for each group of products and clearly indicate the products or
services to which the designation applies. By designating a state or states, you are certifying that you are
authorized and willing to provide the proposed products and services in those states. Designating states in which
you are either unable or unwilling to provide the specified products and services shall be grounds for either
rejection of your Proposal or, if awarded, termination of your Contract.
r 1� i j of ,: i Fr I ,.. i--.s%ur: iVie .; T �..pply 7u4
9 Company Name
7 Company Name
Performance Health Supply LLC
9 State Service Designation
8 Select only one of the following options. If you select "I will NOT serve all States", you must then check
the individual States you wish to serve.
All States I
9 Alabama
9 Alabama
Alabama (AL)
1 Alaska
DAlaska
❑ Alaska (AK)
1 Arizona
dArizona
❑ Arizona (AZ)
1 Arkansas
2 Arkansas
❑ Arkansas (AR)
1 California
3 California (Public Contract Code 20118 & 20652)
❑ California (CA)
1 Colorado
0 Colorado
4
❑ Colorado (CO)
1 Connecticut
5 Connecticut
❑ Connecticut (CT)
1 Delaware
6 Delaware
❑ Delaware (DE)
1 I District of Columbia
d District of Columbia
T
❑ District of Columbia (DC)
1 I Florida
0 Florida
8
❑ Florida (FL)
t'dye i4 of J"i Pdgea
Vviidur: Medw Supply Currtpai'Y' 7U4-23
1
Georgia
9
Georgia
❑ Georgia (GA)
1
Hawaii
1
Hawaii
❑ Hawaii (HI)
1 Idaho
1 Idaho
❑ Idaho (ID)
1 I Illinois
12 Illinois
❑ Illinois (IL)
1 1 Indiana
3 Indiana
❑ Indiana (IN)
1 Iowa
4 Iowa
❑ Iowa (IA)
1 Kansas
5 Kansas
❑ Kansas (KS)
1
Kentucky
fiKentucky
❑ Kentucky (KY)
1
Louisiana
TLouisiana
❑ Louisiana (LA)
1
Maine
8
Maine
❑ Maine (ME)
1
Maryland
9
Maryland
❑ Maryland (MD)
1
Massachusetts
2
a
Massachusetts
❑ Massachusetts (MA)
PdWe i5 of 3 i pcigea Vviidur: Meduu Supply Currtpai'Y_ 7U4-23
1
Michigan
Michigan
❑ Michigan (MI)
1
Minnesota
2
Minnesota
❑ Minnesota (MN)
1 I Mississippi
3 Mississippi
❑ Mississippi (MS)
1 I Missouri
2 Missouri
❑ Missouri (MO)
1 1 Montana
2 Montana
❑ Montana (MT)
1 Nebraska
2 Nebraska
6
❑ Nebraska (NE)
1 I Nevada
7 Nevada
❑ Nevada (NV)
1
New Hampshire
2
8
New Hampshire
❑ New Hampshire (NH)
1
New Jersey
9
New Jersey
❑ New Jersey (NJ)
1
New Mexico
3
New Mexico
❑ New Mexico (NM)
1
New York
3
New York
❑ New York (NY)
1
North Carolina
3
2
North Carolina
❑ North Carolina (NC)
I'aye 16 of .3 1 pduea
Vviidur: Mecluu Supply Cur"Pij - 7U4-23
1
North Dakota
3
North Dakota
❑ North Dakota (ND)
1
Ohio
34
Ohio
❑ Ohio (ON)
1 I Oklahoma
3 Oklahoma
❑ Oklahoma (OK)
1 I Oregon
3 Oregon
❑ Oregon (OR)
1 1 Pennsylvania
3 Pennsylvania
❑ Pennsylvania (PA)
1 Rhode Island
3 Rhode Island
❑ Rhode Island (RI)
1 I South Carolina
3 South Carolina
9
❑ South Carolina (SC)
1
South Dakota
4
Q
South Dakota
❑ South Dakota (SD)
1
Tennessee
1
Tennessee
❑ Tennessee (TN)
1
Texas
4
Texas
❑ Texas (T)C)
1
Utah
3
Utah
❑ Utah (UT)
1
Vermont
4
Vermont
❑ Vermont (VT)
I'aye i 7 of .3 1 pciuea
Vviidur: Mecluu Supply Currtpai'Y' 7U4-23
1 Virginia
5 Virginia
❑ Virginia (VA)
1 Washington
6 Washington
❑ Washington (WA)
1 West Virginia
7 West Virginia
❑ West Virginia (WV)
1 Wisconsin
8 Wisconsin
❑ Wisconsin (WI)
1 Wyoming
4 Wyoming
❑ Wyoming (WY)
Bill Lin
Section I: First Aid Equipment. Products. and Suoolies
Discount (%) off catalog/pricelist for First Aid Equipment and Supplies. Catalog/Pricelist MUST be included or
proposal will not be considered.
Total: 1 25%
Item Notes: PROPOSAL NOTE: Vendors shall submit catalogs)/pricelist(s) with their Proposal response or the
Proposal will not be
considered. Vendors shall submit catalogs)/pricelist(s) with the Proposal in a readily mailable and
readable electronic format, with Excel or searchable POF preferred. No paper catalogs or
manufacturer/vendor websites will be accepted.
Vendors proposing multiple manufacturer product lines and/or catalog/pricelist per line item must submit
the information as follows or proposal may not be considered:
■ Select "Add Alternate" for each additional manufacturer product line and/or catalog/pricelist
proposed
■ Vendor's must list one specific percentage discount for each manufacturer and/or
catalog/pricelist listed
Hoge 18 of 31 pages Vendur: Meduu Supply Gumpany1 704-23
Item Attributes
1. State Name of Catalog/Pricelist Proposed with Discount Percentage
NOT F Do not include SKU, Reference Numbers, Websltes, end/or "See AUeched/Fnclosed"
y I Medco Sports Medicine Catalog
Section I: First Aid Eeuipment. Products, and Supplies
Discount (%) off catalog/pricelist for First Aid Furniture. Catalog/Pricelist MUST be included or proposal will not
be considered.
Total: 25%
Item Notes: PROPOSAL NOTE: Vendors shall submit catalogs)/pricelist(s) with their Proposal response or the
Proposal will not be
considered. Vendors shall submit catalog(s)/pricelist(s) with the Proposal in a readily available and
readable electronic format, with Excel or searchable PDF preferred. No naoer catalogs or
manufacturerivendor websites will he accepted.
Vendors proposing multiple manufacturer product lines and/or catalog/pricelist per line item must submit
the information as follows or proposal may not be considered:
• Select "Add Altemate' for each additional manufacturer product line and/or catalog/pricelist
proposed
to Vendor's must list one specific percentage discount for each manufacturer and/or
catalog/prioslist listed
1. State Name of Catalog/Pricelist Proposed with Discount Percentage
NOTE'. Do not include SKU, Reference Numbers, Webstles, andfor'See AttachadlEnclosed-
IMedco Sports Medicine Catalog
Page 19 of 31 pages Vendor Menco Supply Company 704-23
3
Section I: Eauloment. Products, and Sup Ig les
Discount (%) of catalog/pricelist for Bleeding Control Stations. Catalog/Pricelist MUST be included or
proposal will not be considered.
Total: 25%
Item Notes: PROPOSAL NOTE_ Vendors shall submit catalog(s)/pricelist(s) with their Proposal response or the
Proposal will not be
considered. Vendors shall submit catalog s)/pricelist(s) with the Proposal in a readily available and
readable electronic format, with Excel or searchable PDF preferred. No Daoer catalogs or
manufacturer/vendor websites will be accepted.
Vendors proposing multiple manufacturer product lines and/or catalog/pricelist per line item must submit
the information as follows or proposal may not be considered:
• Select "Add Alternate" for each additional manufacturer product line and/or catalog/pricelist
proposed
• Vendor's must list one specific percentage discount for each manufacturer and/or
catalog/pricelist listed
Item Attributes
1. State Name of Catalog/Pricelist Proposed with Discount Percentage
NOTE: ❑o not include SKU, Reference Numbers, Websites, and/or "See AttachedlEnclosed".
Medco Sports Medicine Catalog
r =f j i r.,-� ks-�: Vuiidur: Metluu Supply Gui 1pai.iy 7U4-2,3
4
Section I: Eauloment. Products, and Sup Ig les
Discount (%) of catalog/pricelist for All Other First Aid, Health, and Nursing Products. Catalog/Pricelist
MUST be included or proposal will not be considered.
Total: 25%
Item Notes: PROPOSAL NOTE: Vendors shall submit catalog(s)/pricelist(s) with their Proposal response or the
Proposal will not be
considered. Vendors shall submit catalog s)/pricelist(s) with the Proposal in a readily available and
readable electronic format, with Excel or searchable PDF preferred. No Daoer catalogs or
manufacturer/vendor websites will be accepted.
Vendors proposing multiple manufacturer product lines and/or catalog/pricelist per line item must submit
the information as follows or proposal may not be considered:
• Select "Add Alternate" for each additional manufacturer product line and/or catalog/pricelist
proposed
• Vendor's must list one specific percentage discount for each manufacturer and/or
catalog/pricelist listed
Item Attributes
1. State Name of CataloglPricelist Proposed with Discount Percentage
NOTE: ❑o not include SKU, Reference Numbers, Websites, and/or "See AttachedlEnclosed".
Medco Sports Medicine Catalog
r - - i 2f j i r.� ks--: Vuiidur: Metluu Supply Gui 1pai.iy 7U4-2,3
5
Section II: Athletic Trainer/Rehabilitation Equipment. Products, and Sugglles
Discount (%) of catalog/pricelist for Athletic Trainer/Rehabilitation Equipment and
Supplies. Catalog/Pricelist MUST be included or proposal will not be considered.
Total: 1 25%
Item Notes: PROPOSAL NOTE: Vendors shall submit catalogs)Ipricelist(s) with their Proposal response or the
Proposal will not be
considered. Vendors shall submit catalogs}Ipricelist(s) with the Proposal in a readily available and
readable electronic format, with Excel or searchable PDF preferred. No paper catalogs or
manufacturerlvendor websites will be accepted.
Vendors proposing multiple manufacturer product lines and/or cataloglpricelist per line item must submit
the information as follows or proposal may not be considered:
• Select "Add Alternate" for each additional manufacturer product line and/or cataloglpricelist
proposed
• Vendor's must list one specific percentage discount for each manufacturer and/or
cataloglpricelist listed
Item Attributes
1. State Name of CataloglPricelist Proposed with discount Percentage
NOTE. Do not include SKU, Reference Numbers, Websites, and/or "See AttachedlEnclosed".
Medco Sports Medicine Catalog
Page 22 of 31 pages Vendur: Meduu Supply Gumpany1 704-23
6
Section II: Athletic Trainer/Rehabilitation Eauipment. Products. and Supplies
Discount (%) of catalog/pricelist for Athletic Trainer/Rehabilitation Furniture. Catalog/Pricelist MIDST be
included or proposal will not be considered.
Total: 25%
Item Notes: PROPOSAL. NOTE: Vendors shall submit catalog(s)/pricelist(s) with their Proposal response or the
Proposal will not be
considered. Vendors shall submit catalog s)/pricelist(s) with the Proposal in a readily available and
readable electronic format, with Excel or searchable PDF preferred. No Daoer catalons or
manufacturer/vendor websites will be accepted.
Vendors proposing multiple manufacturer product lines and/or catalog/pricelist per line item must submit
the information as follows or proposal may not be considered:
• Select "Add Alternate" for each additional manufacturer product line and/or catalog/pricelist
proposed
• Vendor's must list one specific percentage discount for each manufacturer and/or
catalog/pricelist listed
Item Attributes
1. State Name of CataloglPricelist Proposed with Discount Percentage
NOTE: ❑o not include SKU, Reference Numbers, Websites, and/or "See AttachedlEnclosed".
Medco Sports Medicine Catalog
r -- =f j i r.� ks--: Vuiidur: Metluu Supply Gui1pai.iy 7U4-2,3
Section II: Athletic Trainer/Rehabilitation Eauiament. Products. and Sugglles
Discount (%) of catalog/pricelist for All Other Athletic Trainer/Rehabilitation Products. Catalog/Pricelist
MUST be included or proposal will not be considered.
Total: 25%
Item Notes: PROPOSAL NOTE: Vendors shall submit catalog(s)/pricelist(s) with their Proposal response or the
Proposal will not be
considered. Vendors shall submit catalog s)/pricelist(s) with the Proposal in a readily available and
readable electronic format, with Excel or searchable PDF preferred. No Daoer catalogs or
manufacturer/vendor websites will be accepted.
Vendors proposing multiple manufacturer product lines and/or catalog/pricelist per line item must submit
the information as follows or proposal may not be considered:
• Select "Add Alternate" for each additional manufacturer product line and/or catalog/pricelist
proposed
• Vendor's must list one specific percentage discount for each manufacturer and/or
catalog/pricelist listed
Item Attributes
1. State Name of CataloglPricelist Proposed with Discount Percentage
NOTE: ❑o not include SKU, Reference Numbers, Websites, and/or "See AttachedlEnclosed".
Medco Sports Medicine Catalog
r -- -4 '2f j i r.� ks-,: Vuiidur: Metluu Supply Gui1pai.iy 7U4-2,3
0
Section III: Emergency Medical Equipment. Products. and Supplies
Discount (%) of catalog/pricelist for Emergency Medical Equipment and Supplies. Catalog/Pricelist MIDST be
included or proposal will not be considered.
Total: 1 25%
Item Notes: PROPOSAL NOTE: Vendors shall submit catalog(s)/pricelist(s) with their Proposal response or the
Proposal will not be
considered. Vendors shall submit catalog s)/pricelist(s) with the Proposal in a readily available and
readable electronic format, with Excel or searchable PDF preferred. No paper catalogs or
manufacturer/vendor websites will be accepted.
Vendors proposing multiple manufacturer product lines and/or catalog/pricelist per line item must submit
the information as follows or proposal may not be considered:
• Select "Add Alternate" for each additional manufacturer product line and/or catalog/pricelist
proposed
• Vendor's must list one specific percentage discount for each manufacturer and/or
catalog/pricelist listed
Item Attributes
1. State Name of Catalog/Pricelist Proposed with Discount Percentage
NOTE: ❑o not include SKU, Reference Numbers, Websites, and/or "See AttachedlEnclosed".
Medco Sports Medicine Catalog
Vuiidur: Metluu Supply Gui 1pai.iy 7U4-2,3
9
Section III: Emergency Medical Equiament. Products. and Supplies
Discount (%) of catalog/pricelist for All Other Emergency Medical Products. Catalog/Pricelist MUST be
included or proposal will not be considered.
Total: 25%
Item Notes: PROPOSAL NOTE: Vendors shall submit catalog(s)/pricelist(s) with their Proposal response or the
Proposal will not be
considered. Vendors shall submit catalog s)/pricelist(s) with the Proposal in a readily available and
readable electronic format, with Excel or searchable PDF preferred. No paper catalogs or
manufacturer/vendor websites will be accepted.
Vendors proposing multiple manufacturer product lines and/or catalog/pricelist per line item must submit
the information as follows or proposal may not be considered:
• Select "Add Alternate" for each additional manufacturer product line and/or catalog/pricelist
proposed
• Vendor's must list one specific percentage discount for each manufacturer and/or
catalog/pricelist listed
Item Attributes
1. State Name of Catalog/Pricelist Proposed with Discount Percentage
NOTE: ❑o not include SKU, Reference Numbers, Websites, and/or "See AttachedlEnclosed".
Medco Sports Medicine Catalog
r f j i r:� ks--: Vuiidur: Metluu Supply Guiinpai. sy 7U4-2,3
Section IV: Pharmaceuticals and Vaccines
Discount (%) off catalog/pricelist for Pharmaceuticals and Vaccines. CataloglPricelist MUST be included or
proposal will not be considered.
No Bid
Item Notes: PROPOSAL NOTE: Vendors shall submit catalog(s)lpricelist(s) with their Proposal response or the
Proposal will not be
considered. Vendors shall submit catalog(s)lpricelist(s) with the Proposal in a readily available and
readable electronic format, with Excel or searchable PDF preferred. No paper catalogs or
manufacturerivendor websites will be accepted.
Vendors proposing multiple manufacturer product lines and/or cataloglpricelist per line item must submit
the information as follows or proposal may not be considered:
■ Select "Add Alternate" for each additional manufacturer product line andlor cataloglpricelist
proposed
■ Vendor's must list one specific percentage discount for each manufacturer andlor
cataloglpricelist listed
Item Attributes
1. State Name of Catalog/Pricelist Proposed with Discount Percentage
NOTE: Do not include SKU, Reference Numbers, Websites, andlor "See AttachedlEnclosed".
No response
F',� j a �I Of J i F,, �"Ii--; Vuiidur: Meduu Supply Guiapai y_ 7U4-1,3
Section IV: Pharmaceuticals and Vaccines
Discount (%) off catalog/pricelist for Intra-Venous Pharmaceutical Supplies. CataloglPricelist MUST be
included or proposal will not be considered.
No Bid
Item Notes: PROPOSAL NOTE: Vendors shall submit catalog(s)lpricelist(s) with their Proposal response or the
Proposal will not be
considered. Vendors shall submit catalog(s)lpricelist(s) with the Proposal in a readily available and
readable electronic format, with Excel or searchable PDF preferred. No paper catalogs or
manufacturerivendor websites will be accepted.
Vendors proposing multiple manufacturer product lines and/or cataloglpricelist per line item must submit
the information as follows or proposal may not be considered:
■ Select "Add Alternate" for each additional manufacturer product line andlor cataloglpricelist
proposed
■ Vendor's must list one specific percentage discount for each manufacturer andlor
cataloglpricelist listed
Item Attributes
1. State Name of Catalog/Pricelist Proposed with Discount Percentage
NOTE: Do not include SKU, Reference Numbers, Websites, andlor "See AttachedlEnclosed".
No response
F',� j a �S Of J i F,, �"Ii--; Vuiidur: Meduu Supply Guiapai y_ 7U4-1,3
1
2
Section IV: Pharmaceuticals and Vaccines
Discount (%) off catalog/pricelist for Drug Testing Kits and Supplies. Catalog/Pricelist MUST be included or
proposal will not be considered.
No Bid
Item Notes: PROPOSAL NOTE: Vendors shall submit catalog(s)lpricelist(s) with their Proposal response or the
Proposal will not be
considered. Vendors shall submit catalog(s)lpricelist(s) with the Proposal in a readily available and
readable electronic format, with Excel or searchable PDF preferred. No paper catalogs or
manufacturerivendor websites will be accepted.
Vendors proposing multiple manufacturer product lines and/or cataloglpricelist per line item must submit
the information as follows or proposal may not be considered:
■ Select "Add Alternate" for each additional manufacturer product line andlor cataloglpricelist
proposed
■ Vendor's must list one specific percentage discount for each manufacturer andlor
cataloglpricelist listed
Item Attributes
1. State Name of Catalog/Pricelist Proposed with Discount Percentage
NOTE: Do not include SKU, Reference Numbers, Websites, andlor "See AttachedlEnclosed".
No response
F',�a �j Of J i Vuiidur: Meduu Supply Guiapai y_ 7U4-1,3
1
3
Section V: Audiology Equipment and Other Related Items
Discount (%) of cataloglpricelist for Audiology Equipment, Hearing Aids, and Other Related
Items. Catalog/Pricelist MUST be included or proposal will not be considered.
No Sid
Item Notes: PROPOSAL NOTE: Vendors shall submit catalogs)/pricelist(s) with their Proposal response or the
Proposal will not be
considered. Vendors shall submit catalog s)/pricelist(s) with the Proposal in a readily available and
readable electronic format, with Excel or searchable PDF preferred. No paper catalogs or
manufacturer/vendor websites will be accepted.
Vendors proposing multiple manufacturer product lines and/or cataloglpricelist per line item must submit
the information as follows or proposal may not be considered:
• Se1ec:t&Add*AIWaT- ?or each additional manufacturer product line and/or cataloglpricelist
proposed
• Vendor's must list one specific percentage discount for each manufacturer and/or
catalog/pricelist listed
Item Attributes
1. State Name of Catalog/Pricelist Proposed with Discount Percentage
NOTE: Do not include SKu, Reference Numbers, Websites, and/or "See Attach edlEnclosed".
No response
r ,5: 4 j i + Yei dur: Medcu Supply Gumpc.y 7U4-2 3
1
4
Section VI: Drua/Diaanostic/Laboratory Testina Services
Discount (%) of cataloglpricelist for Drug and Alcohol Diagnostic Testing Services (onsite and offsite
including
laboratory services). CataloglPricelist MUST be included or proposal will not be considered.
No Bid
Item Notes: PROPOSAL NOTE: Vendors shall submit catalog(s)lpricelist(s) with their Proposal response or the
Proposal will not be
considered. Vendors shall submit catalog s)lpricelist(s) with the Proposal in a readily available and
readable electronic format, with Excel or searchable PDF preferred. No paper catalogs or
manufacturerivendor websites will be accepted.
Vendors proposing multiple manufacturer product lines and/or cataloglpricelist per line item must submit
the information as follows or proposal may not be considered:
• Select "Add Alternate" for each additional manufacturer product line and/or cataloglpricelist
proposed
• Vendor's must list one specific percentage discount for each manufacturer and/or
cataloglpricelist listed
Item Attributes
1. State Name of CataloglPricelist Proposed with Discount Percentage
NOTE Do not include 5KU. Reference Numbers, Wehsites, and/or "See AttachedlEnclosed
No response
1 Section II: Installation and Repair Service
5
Hourly Labor Rate for Installation/Repair Service of First Aid, Athletic Trainer/Rehabilitation, and
Emergency Medical Equipment and Products - Not to Exceed hourly labor rate for InstallationlRepair
Service of Equipment and Products.
Quantity: 1 UOM: Hourly Labor Rate No Bid
1
6
Section III: Installation and Repair Service
Hourly Labor Rate for Installation/Repair Service of Audiology Equipment and Products - Not to Exceed
hourly labor rate for Installation/Repair Service of Equipment and Products.
Quantity: 1 UOM: Hourly Labor Rate
No Bid
KcSNv� � TwWl. .�
ER
VMPORE EXDICIN0E ' 10OoRilrch IELP 0 554SuiteT ODS a�in 800.222-1934 medco athleties.com
BID # ESTMD3084791
As a valued customer, Medco Sports Medicine is pleased to offer the following discounts and terms on our
entire catalog of items:
Pricing Discount:
• Medco Owned Brands': 25% off catalog price
• Materials and Supplies: 24% off catalog price
• Equipment (Capital) and Furniture: 15% off catalog price 2
•; Athlit:iw Tape. 1.2% off catalog price
■ Athletic Trainer Kits/Bags: 12% off catalog price
Exceptions: The categories of items below have manufacture mandated minimum pricing. Contact Medco Sales Support for pricing:
o Select Treatment Furniture & other Equipment —Game Ready, Normatec, Therm-X, Ice Machines, Whirlpools, AEDs
o Gatorade High School Performance Packages
o Rx Items
5hiaaina Charaes:
Shipping and Handling charges will be applied at the time of order.
o Exceptions: equipment items may incur lift gate, inside delivery, or installation charges.
Jait:°r hems muy tti",r iio:al atdoub� must r ul fet: of
Cusrurn orders.
:gum+` iteans uii yuui uidei may be Lului aiid/ui sice speLitiL. Tease iridiLdte LIN yuui uidei which sire gird/ui
Luluiyuu desire wheii pluLiiig uideis fui tables, stuuls, Labiiiets, UgUipnleiit, etc. Custum uideis sire nur1-
i ` tui iiaule.
As dlwdys, we thank yuu tui the uppuitu(iity to seine yuui uigairiicdtiuri. Aiiy pi iLirlg iriyuir ies may be directed
to MedcuSalesSuppuit@MedcuSupply.Lum ui to Custumei'Suppuit@MedLuSupply.Lum fur general
irlfurmatiuri.
Sincerely,
MedLu Spirits Medidifle
a MEDCQ Owried Brands:
1�% discuatir utc MEDUC) u; Lrtrds erdsu IML-t ides Active Amkle, 3uffiicd, Crarrrt-r, utid Ale-deu Pro-Tra;12L-,
CONFLICT OF INTEREST DISCLOSURE REQUIREMENT
Pursuant to Chapter 176 of the Local Government Code, any person or agent of a person who contracts or
seeks to contract for the sale or purchase of property, goods, or services with a local governmental entity
(i.e. The City of Fort Worth) must disclose in the Questionnaire Forms CIQ (“Questionnaire”) the person’s
affiliation or business relationship that might cause a conflict of interest with the local governmental entity.
By law, the Questionnaire must be filed with the Fort Worth City Secretary no later than seven days after
the date the person begins contract discussions or negotiations with the City, or submits an application or
response to a request for proposals or bids, correspondence, or another writing related to potential
agreement with the City. Updated Questionnaires must be filed in conformance with Chapter 176.
A copy of the Questionnaires Form CIQ is enclosed with submittal documents. The form is also available at
http://www.ethics.state.tx.us/forms/CIQ.pdf.
If you have any questions about compliance, please consult your own legal counsel. Compliance is the
individual responsibility of each person or agent of a person who is subject to the filing requirement. An
offense under Chapter 176 is a Class C misdemeanor.
NOTE: If you are not aware of a Conflict of Interest in any business relationship that you might have
with the City, state Contractor name in the # 1, use N/A in each of the areas on the form. However, a
signature is required in the #7 box in all cases.
CONFLICT OF INTEREST QUESTIONNAIRE FORM CIO
For vendor doing business with local governmental entity
This questionnaire reflects changes made to the law by H.B. 23, Nth Leg., Regular Session. OFFICEUSEONLY
This questionnaire is being filed in accordance with Chapter 176. focal Government Cade, by a vendor who Date Recemed
has a business relationship as defined by Section 176.01 with a local governmental entity and the
vendor meets requirements under Section 176 006(a).
By law this questionnaire must be filed with the records administrator of Me local governmental entity not later
than the 7th business day after the date the vendor becomes aware of facts that require the statement to be
filed See Section 176.006s 1), Local Government Code.
A vendor commits an olleree if the vendor knowingly violates Section 176.006, Local Government Code. An
offense under this section is a misdemeanor.
J Name of vendor who has a business relationship with local governmental entity.
Allison Brooks, Medco Supply Company
J
❑ Check this box It you are filing an update too prevlouslyilled questionnaire. (The law requires that you file an updated
completed questionnaire with the appropriate filing authority not later than the 7th business day after the date on which
you became aware that the originally filed questionnaire was incomplete or inaccurate.)
J Name of local government officer about whom the information is being disclosed.
N/A
Name of Officer
J Describe each employment or other business relationship with the local government officer, or a family member of the
officer, as described by Section 176.003(a)(2)(A). Also describe any family relationship with the local government officer.
Complete subparts A and B for each employment or business relationship described. Attach additional pages to this Form
CIO as necessary.
A. Is the local government officer or a family member of the officer receiving or likely to receive taxable income,
other than investment Income, from the vendor?
Yes X� No
B. Is the vendor receiving or likely to recelve taxable income, other than investment income, from or at the direction
of the local government officer or a family member of the officer AND the taxable income is not received from the
local governmental entity?
Yes FIND
J Describe each employment or business relationship that the vendor named i n Section l maintains with a corporation or
other business entity with respect to which the local government officer serves as an officer or director, or holds an
ownership interest of one percent or more.
J
Check this box if the vendor has given the local government officer or afamily member of the off !car one or more gifts
as described in Section 176.003(a)(2)(B), excluding gifts described in Section 176.003(a-1).
J
AuIJDn 7 SVDDkJ 11/12/25
Signature of vendor doing business with the governmental entity Data
Form provided by Texas Ethics Commission www.ethics stale.tx us Revised 1/1/2021
CONFLICT OF INTEREST QUESTIONNAIRE
For vendor doing business with local gave=rnmental entity
A complete copy of Chapter 176 of the Local Government God& maybe found at http.�,www. statutes-legis-state-tx-us+
DocvLG; htrafl-C-1 176.him. For easy reference_ below are some of the seclions Gi ed on this form -
Local Government Code � 176.001Ma1: "Business relationship" means a connection between two or more parties
based on commercial activity of one of the parties- The term does not include a connection baEse-d on:
(A) a transaction that is subject to rate or fee regulation by a federal, state, or local governmental entity or an
agency of a federal, state, or local governmental entity;
(l3) a transaction conducted at a price and subject to terms available to the public; or
(G) a purchase or lease of goads or services from a person that is chartered by a state or federal agency and
that is subject to regu lar exam i nation by, and reporting to, that agency.
Local Cove mmeni Cade 4176.003(a92)tA) and M:
{a) A local government off icof shall file a conflicts disclosure statement with respect to avendor if:
(2) thevendor:
(A) has an employment or other business relationship with the local government officer or a
family member of the officer that results in the officer or family member receiving taxable
income, other than investment income, that exceeds $2.500 during the 12-month period
preceding the date that the officer becomes aware that
(i) acontract between the local governmental entity and vendor has been executed;
or
(0) the Focal governmental entity is considering entering into a contract with the
vendor:
(8) has giventothelocalgovemmentofficer orafamily member ofthe off iceroneermoregifts
that have an aggregate value of more than $100 in the 12-month period preceding the date the
afffcerbecomes aware that:
0) a contract between the local govern mental entity and ven dor has been exec uted; or
(ii) the local governmental enMy is considering entering into a contractwith the vendor -
Local Government Code A 176.006(a) and {a-1I
(a) Avendor shall file a completed conflict of interest questionnaire if the vendor has a business relationship
with a local govern mental entity and:
( 1 ) has an emp loyment or other busi ness relationship with a I acal government officer of th at local
governmental enW, or a fam ily member of the officer. described by Section 176-003(a)(2) (A);
(2) has given a local government off [oar of that local governmental entity, or a family member of the
officer, one or more gins with the aggregate varl ue specified by Section 176.003(a)(2}(B), excluding any
gift described by Section 176.003(a-1); or
(3) has a family relationship with a local government officer of that local governmental entity-
(a-1) The completed confI ict of interest queshonnaire roust be flied with the appropriate records adminisifator
not later than the seventh business day after the later of:
(1) the date That the vendor:
(A) begins discussions or negotiations to enter into a contract with the local governmental
entity; or
(l3) subm its to the local governmental entity an appiicaton, response to a request for proposals
or bids, correspondence, or another writing related to a potential contract with the local
governmental entity; or
(2) the date the vendor becomes aware:
(A) of an employment or other business relationship with a local government officer, or a
family member of the officer, described by Subsection (a);
(B) that the vendor has given one or mere gifts described by Subsec5on (a); or
(G) of a family relationship with a local government officer -
Form provided by Texas Phics Coreamssion www-ethfrs.stats-ix.us Reutsed 111=1
FORT WORTH.
City Secretary's Office
Contract Routing & Transmittal Slip
Contractor's Name: Performance Health Supply, LLC dba Medco Supply
Subject of the Agreement: Deep Oscillation Therapy Equipment and related supplies
M&C Approved by the Council? * Yes ❑ No
If so, the M&C must be attached to the contract.
Is this an Amendment to an Existing contract? Yes ❑ No
If so, provide the original contract number and the amendment number.
Is the Contract "Permanent"? *Yes ❑ No
If unsure, see backpage for permanent contract listing.
Is this entire contract Confidential? *Yes ❑ No ® Ifonlyspeck information is
Confidential, please list what information is Confidential and the page it is located.
Effective Date: Expiration Date: May 31, 2026
If diereni from the approval date. If applicable.
Is a 1295 Form required? * Yes ❑ No
*If so, please ensure it is attached to the approving M&C or attached to the contract.
Project Number: Ifapplicable. COOP BB 704-23
*Did you include a Text field on the contract to add the City Secretary Contract (CSC)
number? Yes ® No ❑
Contracts need to be routed for CSO Drocessine in the followine order:
1. Katherine Cenicola (Approver)
2. Jannette S. Goodall (Signer)
3. Allison Tidwell (Form Filler)
*Indicates the information is required and if the information is not provided, the contract will be
returned to the department.