1-0.3 Required Forms.pdf

QUALIFICATIONS & FAILURE TO PERFORM QUESTIONNAIRE

All qualification packages must be submitted with the PROPOSAL to be considered. No exceptions.

PURPOSE: To provide Suwannee County with reasonable assurance that the Proposer/Bidder has the financial assets, resources, workforce, and experience to complete the work and fulfill an agreement with the County.

FIRM NAME:

BUSINESS ADDRESS:

CITY, STATE, ZIP:

PHONE NUMBER WITH AREA CODE:

EMAIL:

The undersigned warrants the truth and accuracy of all statements and answers herein contained.

Include additional sheets if necessary.

1. What is the Proposer’s/Bidders current Florida licensure for the work proposed?

2. Number of years the Proposer’s/Bidder’s organization has been in business.

3. Describe and provide contact information for current projects that you have underway. Will you have a project(s) underway that might interfere with the start of the work and completion schedule?

The proposer/bidder is not limited to three (3) projects; please add additional projects if more than three (3) projects.

Project 1:

Name of Project Owner:

Telephone Number:

Address:

Date Started: Date Completed:

Contract Value:

Team Members:

Project Description:

Project 2:

Name of Project Owner:

Telephone Number:

Address:

Date Started: Date Completed:

Contract Value:

Team Members:

Project Description:

Project 3:

Name of Project Owner:

Telephone Number:

Address:

Date Started: Date Completed:

Contract Value:

4. List and provide a brief description of projects completed similar in type, size, or larger, and nature as the one proposed in this RFQ. The proposer/bidder is not limited to three (3) projects; please add additional projects if more than three (3) projects.

Project 1:

Name of Project Owner:

Telephone Number:

Address:

Date Started: Date Completed:

Contract Value:

Project 2:

Owner:

Telephone Number:

Address:

Date Started: Date Completed:

Contract Value:

Owner:

Telephone Number:

Address:

Date Started: Date Completed:

Contract Value:

5. List any additional references you would like to include outside of projects similar in scope to this project.

Project 1:

Name of Project Owner:

Telephone Number:

Address:

Date Started: Date Completed:

Contract Value:

Project 2:

Owner:

Telephone Number:

Address:

Date Started: Date Completed:

Contract Value:

Owner:

Telephone Number:

Address:

Date Started: Date Completed:

Contract Value:

6. Has the Firm ever worked within Suwannee County? If yes, what project(s)? Limit to three (3).

7. Has the Firm failed to complete any work awarded (contracted)? If yes, where and why?

8. List all past and current project conflicts, litigations, arbitrations, mediations, informal settlement discussions, or disputes involving the Proposer/Bidder (Company) for the last three (3) years and outcome. Fully describe the circumstances (use additional sheets if necessary).

Signature of Person Submitting Application/Date

Printed Name of Person Submitting Application

Title of Person Submitting Application

INDEMNIFICATION & HOLD HARMLESS

To the fullest extent permitted by law, Contractor shall indemnify and hold harmless COUNTY, its offices and employees from liabilities, damages, losses, and costs including, but not limited to reasonable attorney fees, to the extent caused by the negligence, recklessness, or intentional wrongful conduct of the CONTRACTOR and other persons employed or utilized by the CONTRACTOR in the performance of this CONTRACT.

Signed:

Name:

Title:

Firm:

EQUAL OPPORTUNITY/AFFIRMATIVE ACTION STATEMENT

1. The contractors and all subcontractors hereby agree to a commitment to the principles and practices of equal opportunity in employment and to comply with the letter and spirit of federal, state, and local laws and regulations prohibiting discrimination based on race, color, religion, national region, sex, age, handicap, marital status, and political affiliation or belief.

2. The contractor agrees to comply with Executive Order 11246, as amended, and to comply with specific affirmative action obligations contained therein.

Signed:

Title:

Firm:

ETHICS CLAUSE

The undersigned certifies, to the best of his or her knowledge and belief, that:

No federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any agency, a member of congress, an officer or employee of congress, or an employee of a member of congress in connection with the awarding of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative agreement.

If any funds other than federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a member of congress, an officer or employee of congress, or an employee of a member of congress in connection with this federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, “Disclosure Form to Report Lobbying,” in accordance with its instructions.

The undersigned shall require that the language of this certification be included in the award documents for all sub - awards at all tiers (including subcontracts, sub-grants, and contracts under grants, loans, and cooperative agreements) and that all sub-recipients shall certify and disclose accordingly.

This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, Title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

Signature:

Date:

Name of Authorized Individual:

Name of Company/Organization:

Address of Company/Organization:

CONFLICT OF INTEREST DISCLOSURE FORM

Please mark which of the following applies to you/your company:

I hereby attest that no Suwannee County Board of County Commissioners employee(s), elected officials(s), of if any of its agencies is also an owner, corporate officer, agency, employee, etc., of their corporation/partnership/individual business.

The following person(s) name(s) and position(s) with your business do have a conflict of interest:

NAME(S) POSITION(S)

(Signature)

Title:

Date: ___________________________

ANTI-COLLUSION STATEMENT

I hereby attest that I am the person responsible within my company for the final decision as to the price(s) and amount of this bid or, if not, that I have written authorization, enclosed herewith, from that person to make the statements set out below on his or her behalf and on behalf of my company.

I further attest that:

1. The price(s) and amount of this bid have been arrived at independently, without consultation, communication, or agreement for the purpose or with the effect of restricting competition with any other company or person who is a bidder or potential prime bidder.

2. Neither the price(s) nor the amount of this bid have been disclosed to any other company or person who is a bidder or potential prime bidder on this project, and will not be so disclosed prior to bid opening.

3. Neither the prices nor the amount of the bid of any other company or person who is a bidder or potential prime bidder on this project have been disclosed to me or my company.

4. No attempt has been made to solicit, cause or induce any company or person who is a bidder or potential prime bidder to refrain from bidding on this project, or to submit a bid higher than the bid of this company, or any intentionally high or noncompetitive bid or other form of complementary bid.

5. No agreement has been promised or solicited for any other company or person who is a bidder or potential prime bidder on this project to submit an intentionally high, noncompetitive or other form of complementary bid on this project.

6. The bid of my company is made in good faith and not pursuant to any consultation, communication, agreement or discussion with, or inducement or solicitation by or from any company or person to submit any intentionally high, noncompetitive or other form of complementary bid.

7. My company has not offered or entered into a subcontract or agreement regarding the purchase or sale of materials or services from any company or person, or offered, promised or paid cash or anything of value to any company or person, whether in connection with this or any other project, in consideration for an agreement or promise by any company or person to refrain from bidding or to submit any intentionally high, noncompetitive or other form of complementary bid or agreeing or promising to do so on this project.

8. My company has not accepted or been promised any subcontract or agreement regarding the sale of materials or services to any company or person and has not been promised or paid cash or anything of value by any company or person, whether in connection with this or any other project, in consideration for my company's submitting any intentionally high, noncompetitive or other form of complementary bid, or agreeing or promising to do so, on this project.

9. I have made a diligent inquiry of all members, officers, employees, and agents of my company with responsibilities relating to the preparation, approval or submission of my company's bid on this project and have been advised by each of them that he or she has not participated in any communication, consultation, discussion, agreement, collusion, or other conduct inconsistent with any of the statements and representations made in this affidavit.

10. I understand and my company understands that any misstatement in this affidavit is and shall be treated as a fraudulent concealment from the Florida Department of Transportation, of the true facts relating to submission of bids for this contract.

ANTI-COLLUSION STATEMENT - SIGNATURE

I DECLARE UNDER PENALTY OF PERJURY IN THE SECOND DEGREE, AND ANY OTHER APPLICABLE STATE OR FEDERAL LAWS, THAT THE STATEMENTS MADE ON THIS DOCUMENT ARE TRUE AND COMPLETE TO

THE BEST OF MY KNOWLEDGE.

Signature Date

Title

Company Name

DEBARMENT

Contractor Covered Transactions

(1) The prospective contractor,_______________________________, of the Sub-Recipient certifies, by submission of this document, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency.

(2) Where the Sub-Recipient’s subcontractor is unable to certify to the above statement, the prospective subcontractor shall attach an explanation to this form.

Signature Date

Title

Company Name

Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion