ࡱ> MOFGHIJKL5ưbjbjr2r27XhXh6iiiii}}}89L}JV:ZM i   $V/iy y y /ii4$$$y ii $y $$yɃpWX!`Q0J֍g"H֍ɃɃ֍imy y $y y y y y //#y y y Jy y y y ֍y y y y y y y y y c /:ZaBcznik nr 1 do SWZ Formularz ofertowy Ubiegajc si o udzielenie zamwienia publicznego na dostaw wyrobw medycznych z podziaBem na 26 cz[ci dla Powiatowego Szpitala im. WBadysBawa BiegaDskiego w IBawie Numer postpowania: 21/2022 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*: 1. Mikroprzedsibiorstwem1 2. maBym przedsibiorstwem 3. [rednim przedsibiorstwem1 4. Jednoosobowa dziaBalno[ gospodarcza 5. Osoba fizyczna nie prowadzca dziaBalno[ci gospodarczej 6. 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 Filtry przeciwbakteryjne Warto[ cz[ci brutto ...........................................................................................................zB (SBownie:............................................................................................................................... ) Termin dostawy & & & & & & & & .. (maksymalnie do 6 dni roboczych od zBo|enia zamwienia)Zadanie nr 2 Silikon w sprayu Warto[ cz[ci brutto ...........................................................................................................zB (SBownie:............................................................................................................................... ) Termin dostawy & & & & & & & & .. (maksymalnie do 6 dni roboczych od zBo|enia zamwienia)Zadanie nr 3 Stapler I Warto[ cz[ci brutto ...........................................................................................................zB (SBownie:............................................................................................................................... ) Termin dostawy & & & & & & & & .. (maksymalnie do 6 dni roboczych od zBo|enia zamwienia)Zadanie nr 4 Klipsy do klipsowanicy laparoskopowej wraz z u|yczeniem klipsownicy Warto[ cz[ci brutto ...........................................................................................................zB (SBownie:............................................................................................................................... ) Termin dostawy & & & & & & & & .. (maksymalnie do 6 dni roboczych od zBo|enia zamwienia)Zadanie nr 5 Zestaw do punkcji opBucnej i drena|u jamy opBucnej Warto[ cz[ci brutto ...........................................................................................................zB (SBownie:............................................................................................................................... ) Termin dostawy & & & & & & & & .. (maksymalnie do 6 dni roboczych od zBo|enia zamwienia)Zadanie nr 6 Systemy bezigBowe Warto[ cz[ci brutto ...........................................................................................................zB (SBownie:............................................................................................................................... ) Termin dostawy & & & & & & & & .. (maksymalnie do 6 dni roboczych od zBo|enia zamwienia)Zadanie nr 7 Sprzt do |ywienia dojelitowego Warto[ cz[ci brutto ...........................................................................................................zB (SBownie:............................................................................................................................... ) Termin dostawy & & & & & & & & .. (maksymalnie do 6 dni roboczych od zBo|enia zamwienia)Zadanie nr 8 Termometr bezdotykowy Warto[ cz[ci brutto ...........................................................................................................zB (SBownie:............................................................................................................................... ) Termin dostawy & & & & & & & & .. (maksymalnie do 6 dni roboczych od zBo|enia zamwienia)Zadanie nr 9 IgBy iniekcyjne bezpieczne Warto[ cz[ci brutto ...........................................................................................................zB (SBownie:............................................................................................................................... ) Termin dostawy & & & & & & & & .. (maksymalnie do 6 dni roboczych od zBo|enia zamwienia)Zadanie nr 10 Akumulatory do LifePack Warto[ cz[ci brutto ...........................................................................................................zB (SBownie:............................................................................................................................... ) Termin dostawy & & & & & & & & .. (maksymalnie do 6 dni roboczych od zBo|enia zamwienia)Zadanie nr 11 Jednorazowa miarka papierowa dla noworodkw Warto[ cz[ci brutto ...........................................................................................................zB (SBownie:............................................................................................................................... ) Termin dostawy & & & & & & & & .. (maksymalnie do 6 dni roboczych od zBo|enia zamwienia)Zadanie nr 12 Kaseta do analizatora Warto[ cz[ci brutto ...........................................................................................................zB (SBownie:............................................................................................................................... ) Termin dostawy & & & & & & & & .. (maksymalnie do 6 dni roboczych od zBo|enia zamwienia)Zadanie nr 13 Akcesoria do diatermii EMED i AESCULAP Warto[ cz[ci brutto ...........................................................................................................zB (SBownie:............................................................................................................................... ) Termin dostawy & & & & & & & & .. (maksymalnie do 6 dni roboczych od zBo|enia zamwienia)Zadanie nr 14 KoDcwka do odsysania pola operacyjnego Warto[ cz[ci brutto ...........................................................................................................zB (SBownie:............................................................................................................................... ) Termin dostawy & & & & & & & & .. (maksymalnie do 6 dni roboczych od zBo|enia zamwienia)Zadanie nr 15 Fartuchy chirurgiczne sterylne Warto[ cz[ci brutto ...........................................................................................................zB (SBownie:............................................................................................................................... ) Termin dostawy & & & & & & & & .. (maksymalnie do 6 dni roboczych od zBo|enia zamwienia)(28Ntvxz ﹩wj]PFP6hLhKOJPJQJ\^JhZ_.OJQJ^JhZ_.hZ_.OJQJ^JhLh{OJQJ^JhLhOOJQJ^JhOOJQJ^J&hOhK5CJOJQJ\^JaJ&hOhO5CJOJQJ\^JaJhLh( 6OJQJ]^J"hLh( 56CJOJQJ^JhLh{5CJOJQJ^J'hLh{5CJOJQJ^JmHsHhLh( 5CJOJQJ^J8Nvxz  2 4 $$Ifa$ $^a$gd{$ dha$gd{$a$gd{$ x*$a$gd( $`a$gd( $a$gd6d$d^a$gdKgd( $a$gd(    2 4 X   & ( : < L N P R l n p r t  D ־yyyylllllllh_:h_:OJQJ^JhLh{OJPJQJ^JhLh{5OJQJ^JhLh{6OJQJ^JhLh{OJQJ^JhLhFOJQJ^JhLh( OJQJ^JhO5OJQJ^JhZ_.5OJQJ^JhLh^5OJQJ^JhLh( 5@OJQJ^J*   & ( : skd$$Ifld0w#wFe t0644 lBalyt@ $$Ifa$: < L N P |sss $$Ifa$kd$$Ifl0w#wFe t0644 lBalyt@P R l n p xxl $$Ifa$gd{ $$Ifa$}kdJ$$Ifl0w#we t0644 lalyt@p r t  D ( T xllllllll $$Ifa$gd_: $$Ifa$}kd$$Ifl0w#we t0644 lalyt@ ( R T V |4n涥}i[NNNhLh( OJQJ^JhLh( 5OJQJ^J'hLh{5@CJOJQJ^JaJ&hLhK6CJOJQJ]^JaJ&hLh6CJOJQJ]^JaJ hLhKCJOJQJ^JaJ&hLhK5CJOJQJ\^JaJhLh@OJQJ^JhLh{OJPJQJ^JhLh{OJQJ^Jh_:h_:OJQJ^JT V } $$Ifa$gd@ $$Ifa$lkd$$Ifl4## t0644 lalyt@ |{j_S $d^da$gd{ xgd! ^`gdK ! xgdK $^a$gd{lkd$$Ifl`## t0644 lalyt@n "B@ ""@΅mm]J$hXhX5B*OJQJ^JphhZ_.5B*OJQJ^Jph$hZ_.hZ_.5B*OJQJ^Jph'hOhO5B*OJQJ\^JphhXhXOJQJ^JhOhOOJQJ^J!hZ_.5B*OJQJ\^Jph'hZ_.hZ_.5B*OJQJ\^Jphhi$gB*OJQJ^JphhLh( OJQJ^J!hLh( B*OJQJ^Jph"@"@_MMMdh$1$7$8$H$IfgdXpkd$$IfTF#H$ t0644 layt%%Tdh$1$7$8$H$IfgdO$ & F n,0,x1$^,`a$gd( 2|||dh$1$7$8$H$IfgdXpkd$$$IfTFU#H$ t0644 layt%%TR2xz:<>x~ !!!!""#####$%%%&&&&&ϼϼϖϖhZ_.5B*OJQJ^Jph$hZ_.hZ_.5B*OJQJ^Jph$hOhO5B*OJQJ^Jph$hXhX5B*OJQJ^Jph'hOhO5B*OJQJ\^JphhXhXOJQJ^JhX5B*OJQJ^Jph3z<|||dh$1$7$8$H$IfgdXpkd$$IfTF#H$ t0644 layt%%T<> |||dh$1$7$8$H$IfgdXpkd($$IfTFU#H$ t0644 layt%%T "#|||dh$1$7$8$H$IfgdXpkd$$IfTFU#H$ t0644 layt%%T###%&|||dh$1$7$8$H$IfgdXpkd,$$IfTFU#H$ t0644 layt%%T&&&))|||dh$1$7$8$H$IfgdXpkd$$IfTFU#H$ t0644 layt%%T&&&'V''f())V)))))))2*N++,,2,,,,, - -:-B-~-*/:/B/~////0B0D0z0j112b2z2333N3P3333n555ïïïïhLP5OJQJ\^JhLPhLP5OJQJ\^J'hOhX5B*OJQJ\^Jph$hXhX5B*OJQJ^JphhXhXOJQJ^JhZ_.5OJQJ\^JhZ_.hZ_.5OJQJ\^J9))),,|||dh$1$7$8$H$IfgdXpkd0$$IfTFU#H$ t0644 layt%%T,, -*//|||dh$1$7$8$H$IfgdXpkd$$IfTFU#H$ t0644 layt%%T//D0b23|||dh$1$7$8$H$IfgdXpkd4$$IfTFU#H$ t0644 layt%%T33P3n56|||dh$1$7$8$H$IfgdXpkd$$IfTFU#H$ t0644 layt%%T55666|6~6677888>9@9B99999::;;;<<n<p<r<<<<==>4>>????zzzzz||||V}X}Z}}}}>~~؀ڀ̼̼̼̭̼̼UhLP5OJQJ\^JhLPhLP5OJQJ\^J'hOhX5B*OJQJ\^Jph$hXhX5B*OJQJ^JphhXhXOJQJ^JD66~68@9|||dh$1$7$8$H$IfgdXpkd8 $$IfTFU#H$ t0644 layt%%T@9B99;p<|||dh$1$7$8$H$IfgdXpkd $$IfTFU#H$ t0644 layt%%Tp<r<<>?|||dh$1$7$8$H$IfgdXpkd< $$IfTFU#H$ t0644 layt%%T??z|X}|||dh$1$7$8$H$IfgdXpkd $$IfTFU#H$ t0644 layt%%TZadanie nr 16 Urzdzenie wielorazowego u|ytku do usuwania zszywek skrnych Warto[ cz[ci brutto ...........................................................................................................zB (SBownie:............................................................................................................................... ) Termin dostawy & & & & & & & & .. (maksymalnie do 6 dni roboczych od zBo|enia zamwienia)Zadanie nr 17 Sterylny zestaw do cicia cesarskiego Warto[ cz[ci brutto ...........................................................................................................zB (SBownie:............................................................................................................................... ) Termin dostawy & & & & & & & & .. (maksymalnie do 6 dni roboczych od zBo|enia zamwienia)Zadanie nr 18 Kateter do szynowania jelit Warto[ cz[ci brutto ...........................................................................................................zB (SBownie:............................................................................................................................... ) Termin dostawy & & & & & & & & .. (maksymalnie do 6 dni roboczych od zBo|enia zamwienia)Zadanie nr 19 Zestawy z Veressa i Verso Warto[ cz[ci brutto ...........................................................................................................zB (SBownie:............................................................................................................................... ) Termin dostawy & & & & & & & & .. (maksymalnie do 6 dni roboczych od zBo|enia zamwienia)Zadanie nr 20 Rkawice diagnostyczne Warto[ cz[ci brutto ...........................................................................................................zB (SBownie:............................................................................................................................... ) Termin dostawy & & & & & & & & .. (maksymalnie do 6 dni roboczych od zBo|enia zamwienia)Zadanie 21 Akcesoria do pompy dozujcej kontrast Warto[ cz[ci brutto ...........................................................................................................zB (SBownie:............................................................................................................................... ) Termin dostawy & & & & & & & & .. (maksymalnie do 6 dni roboczych od zBo|enia zamwienia)Zadanie nr 22 Akcesoria do monitorw Philips IntelliVeu x3 Warto[ cz[ci brutto ...........................................................................................................zB (SBownie:............................................................................................................................... ) Termin dostawy & & & & & & & & .. (maksymalnie do 6 dni roboczych od zBo|enia zamwienia)Zadanie nr 23 Cewnik do indukcji porodu Warto[ cz[ci brutto ...........................................................................................................zB (SBownie:............................................................................................................................... ) Termin dostawy & & & & & & & & .. (maksymalnie do 6 dni roboczych od zBo|enia zamwienia)Zadanie nr 24 Zrodki dezynfekcyjne do myjni CYW-DUO-dwukomorowa Warto[ cz[ci brutto ...........................................................................................................zB (SBownie:............................................................................................................................... ) Termin dostawy & & & & & & & & .. (maksymalnie do 6 dni roboczych od zBo|enia zamwienia)Zadanie nr 25 Amnicatory Warto[ cz[ci brutto ...........................................................................................................zB (SBownie:............................................................................................................................... ) Termin dostawy & & & & & & & & .. (maksymalnie do 6 dni roboczych od zBo|enia zamwienia)Zadanie nr 26 Ostrza chirurgiczne Warto[ cz[ci brutto ...........................................................................................................zB (SBownie:............................................................................................................................... ) Termin dostawy & & & & & & & & .. (maksymalnie do 6 dni roboczych od zBo|enia zamwienia) O[wiadczamy, |e zapoznali[my si z tre[ci Specyfikacji Warunkw Zamwienia (w tym z projektem umowy) i nie wnosimy do niej zastrze|eD oraz przyjmujemy warunki w niej zawarte; O[wiadczamy, |e uwa|amy si za zwizanych niniejsz ofert na czas wskazany w Specyfikacji Warunkw Zamwienia; O[wiadczamy, |e przedmiot zamwienia zamierzamy zrealizowa bez udziaBu/z udziaBem* podwykonawcw; Podwykonawcom zamierzamy powierzy poni|sze cz[ci zamwienia (wypeBni je|eli dotyczy) Lp.Cz[ci zamwienia, ktre Wykonawca powierzy do wykonania podwykonawcy,nazwa podwykonawcw (je|eli jest znana)   O[wiadczamy, |e wypeBnili[my obowizki informacyjne przewidziane w art. 13 lub art. 14 RODO wobec osb fizycznych, od ktrych dane osobowe bezpo[rednio lub po[rednio pozyskali[my w celu ubiegania si o udzielenie zamwienia publicznego w niniejszym postpowaniu.**) O[wiadczamy, |e w przypadku przyznania niniejszego zamwienia zobowizujemy si do podpisania umowy na warunkach, w terminie i miejscu okre[lonym przez Zamawiajcego; O[wiadczamy, |e odpis lub informacja z Krajowego Rejestru Sdowego lub z Centralnej Ewidencji i Informacji o DziaBalno[ci Gospodarczej w zakresie art. 109 ust. 1 pkt 4) ustawy, jest dostpny bezpBatnie pod adresem strony internetowej: & & & & & & & & & & & & & & & & & & & & & & & & & & ................& & & & & & & & & & & OZWIADCZAM, |e w przypadku przyznania niniejszego zamwienia osob odpowiedzialn za nadzr nad realizacj umowy bdzie & & & & & & & & & & & & & & & & Wraz z ofert skBadamy nastpujce o[wiadczenia i dokumenty: & & & & & & & & & & & & & & & & - zaBcznik nr & & & & .. & & & & & & & & & & & & & & & ... - zaBcznik nr & & & & .. & & & & & & & & & & & & & & & & - zaBcznik nr & & & & .. & & & & & & & & & & & & & & & & & & & ..................................................................... miejscowo[ i data (upeBnomocniony(ieni) przedstawiciel(e) Wykonawcy) Informacja dla Wykonawcy: * niepotrzebne skre[li ** w przypadku, gdy Wykonawca nie przekazuje danych osobowych innych ni| bezpo[rednio jego dotyczcych lub zachodzi wyBczenie stosowania obowizku informacyjnego, stosownie do art. 13 ust. 4 lub art. 14 ust. 5 RODO Wykonawca nie skBada o[wiadczenia (usunicie tre[ci o[wiadczenia nastpuje np. przez jego wykre[lenie).     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