ࡱ> !5Bpbjbjr2r27XhXh ) 555III8 I :#!#!#!W""y" "ˆˆˆˆˆˆ$iu5"W"W"""55#!#!4[$$$"X5#!5#!$"$${#!]i"pq0#5""$"""""#""""""""""""""""c :ZaBcznik nr 1 do SWZ Formularz ofertowy Ubiegajc si o udzielenie zamwienia publicznego na dostaw odczynnikw wraz z dzier|aw analizatora z podziaBem na 2 zadania dla Laboratorium Diagnostycznego Powiatowego Szpitala im. WBadysBawa BiegaDskiego w IBawie Numer postpowania: 19/2022 Ja/My ni|ej podpisani: (imi i nazwisko): & & & & & & & & & & & & & & & & & & & & & & . wystpujcy w imieniu i na rzecz: PeBna nazwa firmy: Adres firmy:NIP: e-mail: Nr KRS: Nr telefonu:  Wykonawca jest*: Mikroprzedsibiorstwem1 maBym przedsibiorstwem [rednim przedsibiorstwem1 Jednoosobowa dziaBalno[ gospodarcza Osoba fizyczna nie prowadzca dziaBalno[ci gospodarczej Inny rodzaj *niewBa[ciwe skre[liOsoba uprawniona do kontaktu z Zamawiajcym: Nr telefonu: e-mail: OZWIADCZAM, |e naszym peBnomocnikiem dla potrzeb niniejszego zamwienia jest: & & & & & & & & & & & & & & & & & & & & & & & & & .& & & & & & & & & & .& & & & & & & (WypeBniaj jedynie przedsibiorcy skBadajcy wspln ofert) Oferujemy realizacj przedmiotowego zamwienia w zakresie zgodnym z wymaganiami Zamawiajcego okre[lonymi w Specyfikacji Warunkw Zamwienia na: Zadanie nr 1 - Serwis i zakup odczynnikw do analizatora RKZ ABL 90 FLEX bdcego wBasno[ci Powiatowego Szpitala im. WB. BiegaDskiego w IBawie Warto[ cz[ci brutto ...........................................................................................................zB (SBownie:.................................................................................................................................. ) Lp. Parametr TAK lub NIE 1. Termin dostawy do 3 dni wBcznie Termin dostawy do 5 dni wBcznie Termin dostawy powy|ej 5 dni 40 pkt. 20 pkt. 5pkt.  Zadanie nr 2 - Dzier|awa analizatora parametrw krytycznych oraz zakup odczynnikw, materiaBw eksploatacyjnych, kontroli i kalibratorw do wykonania 3 600 oznaczeD na okres 12 miesicy. Warto[ cz[ci brutto ...........................................................................................................zB (SBownie:.................................................................................................................................. ) Parametry oceniane (jako[ciowe): Lp. Parametr TAK lub NIE 1. Termin dostawy do 3 dni wBcznie Termin dostawy do 5 dni wBcznie Termin dostawy powy|ej 5 dni 20 pkt. 10 pkt. 5pkt. 2. Czas reakcji serwisu do 24 godzin Tak  20 pkt. 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Por. zalecenie Komisji z dnia 6 maja 2003 r. dotyczce definicji mikroprzedsibiorstw oraz maBych i [rednich przedsibiorstw (Dz.U. L 124 z 20.5.2003, s. 36). Te informacje s wymagane wyBcznie do celw statystycznych. Mikroprzedsibiorstwo: przedsibiorstwo, ktre zatrudnia mniej ni| 10 osb i ktrego roczny obrt lub roczna suma bilansowa nie przekracza 2 milionw EUR. MaBe przedsibiorstwo: przedsibiorstwo, ktre zatrudnia mniej ni| 50 osb i ktrego roczny obrt lub roczna suma bilansowa nie przekracza 10 milionw EUR. Zrednie przedsibiorstwa: przedsibiorstwa, ktre nie s mikroprzedsibiorstwami ani maBymi przedsibiorstwami i ktre zatrudniaj mniej ni| 250 osb i ktrych roczny obrt nie przekracza 50 milionw EUR lub roczna suma bilansowa nie przekracza 43 milionw EUR.     PAGE 14 Strona PAGE3 z NUMPAGES3  Powiatowy Szpital im. WBadysBawa BiegaDskiego w IBawie ul. Gen. WB. 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