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# RFB 24 - 003 ATTACHMENT A – COST FORM

Vendor Name: ___

Instructions:

Vendors shall enter pricing on this cost sheet.

Vendors shall not alter the language or format of the price sheet or they shall be deemed non-responsive.

• Vendors shall not add additional information to the cost sheet(s) or they shall be deemed non-responsive.

• Vendors shall enter cost as final (not estimated or average) amounts or they shall be deemed non-responsive.


<table border=1 style='margin: auto; word-wrap: break-word;'><tr><td colspan="2">Cost</td><td style='text-align: center; word-wrap: break-word;'></td></tr><tr><td style='text-align: center; word-wrap: break-word;'>Description</td><td style='text-align: center; word-wrap: break-word;'>Qty</td><td style='text-align: center; word-wrap: break-word;'>Cost</td></tr><tr><td style='text-align: center; word-wrap: break-word;'>One (1) 2023 One Exam Room Mobile Clinic ADA units with a 2023 Van E350
DRW 1 passenger &amp; driver capability (or similar vehicle) with the following accessories:
• Blood Draw Chair/ Phlebotomy Chair
• ADA Compliant Lift
• Overall Length 22&#x27; 11.5&quot;
• 110V Outlet
• Double W/C Lift Door - Deluxe
• Braun Century Lift NCL919, 34&quot; Wide
• Pull 110V 12 Gauge Cable for Rooftop A/C
• Wheel Liners Stainless Steel E350/450 w/Valve Ext.
• Exam Bench
• Check In Desk with Desk Chair
• Accucold Medical Grade Refrigerator 5.5 cu ft
• Sharps Disposable System
• Waiting Area Bench
• Eye Wash Station
• Vent Fan Header Compartment w/ Cover
• Smoke/Carbon Detector</td><td style='text-align: center; word-wrap: break-word;'>1</td><td style='text-align: center; word-wrap: break-word;'></td></tr><tr><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td></tr></table>