10-09 - 27-02 - VENDOR ACKNOWLEDGEMENT FORM.pdf

VENDOR ACKNOWLEDGEMENT FORM

Reading and attesting to the items below are required components of your Solicitation response in order for your Solicitation submittal to be considered as responsive. Therefore, by submitting this Vendor Acknowledgement Form, the person submitting this form certifies and affirms under penalty of perjury that:

1) They he/she is an officer or duly authorized agent acting with the legal ability to bind the party(ies) named below in all respects with regards to this Solicitation and this representation is made for the express purpose of it being relied upon by the AUTHORITY.

2) The Vendor Representative has personal knowledge that the foregoing is true and accurate and satisfies all legal requirements detailed below:

3) The Vendor acknowledges and agrees to be bound to the General Conditions, Instructions, and Information for Vendors (for

ITB)/General Information (for RFP/RFQ) provided herein.

4) Drug-Free Workplace: In accordance with Florida Statute 287.087, Vendor certifies to be engaged in the following:

a) Publish a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the workplace and specifying the actions that will be taken against employees for violations of such prohibition.

b) Inform employees about the dangers of drug abuse in the workplace, the business’s policy of maintaining a drug-free workplace, any available drug counseling, rehabilitation, and employee assistance programs, and the penalties that may be imposed upon employees for drug abuse violations.

c) Give each employee engaged in providing the commodities or contractual services that are under this solicitation a copy of the statement specified in subsection (1).

d) In the statement specified in subsection (1), notify the employees that, as a condition of working on the commodities or contractual services that are under this solicitation, the employee will abide by the terms of the statement and will notify the employer of any conviction of, or plea of guilty or nolo contendere to, any violation of chapter 893, or of any controlled substance law of the United States or any state, for a violation occurring in the workplace, no later than five (5) days after such conviction.

e) Impose a sanction on or require the satisfactory participation in a drug abuse assistance or rehabilitation program if such is available in the employee’s community, by any employee who is so convicted.

f) Impose a sanction on or require the satisfactory participation in a drug abuse assistance or rehabilitation program if such is available in the employee’s community, by any employee who is so convicted.

g) Make a good faith effort to continue to maintain a drug-free workplace through implementation of this section.

5) Non-Collusion Certification: That she/he is an officer or duly authorized agent acting on behalf of the party(ies) making the foregoing , that such Solicitation Response is genuine and not collusive or sham; that said Vendor has not colluded, conspired, connived or agreed, directly or indirectly with any Vendor or person, to put in a sham response or to refrain from responding and has not in any manner, directly or indirectly, sought by agreement or collusion or communication or conference with any person, to fix the price or affiant or any other Vendor or to fix any overhead, profit or cost element of said price or that of any other Vendor, or to secure any advantage against the AUTHORITY, or any person interested in the proposed contract and that all statement in said Solicitation response are true.

6) Scrutinized List Certification: Vendor certifies:

a) It does not Participate in a boycott of Israel; and

b) Is not on the Scrutinized Companies that boycott Israel list; and

c) Is not on the Scrutinized Companies with activities in Sudan list; and

d) Is not on the Scrutinized Companies with activities in The Iran Terrorism Sectors list; and

e) Has not engaged in business operations in Cuba or Syria

7) Conditions for Emergency/Hurricane or Disaster: Vendor freely and voluntarily understands and agrees that it is hereby made a part of this Solicitation Response that before, during and after a public emergency, disaster, hurricane, flood, or acts of God that the Solid Waste Authority of Palm Beach County shall require a “first priority” basis for goods and services. It is vital and imperative that the majority of citizens are protected from any emergency situation which may threaten public health and safety, as determined by the Solid Waste Authority of Palm Beach County. Vendor/Contractor agrees to rent/sell/lease all goods and services to the Solid Waste Authority of Palm Beach County, or any other government entity as opposed to a private citizen, on a first priority basis. The Solid Waste Authority of Palm Beach

County expects to pay a fair and reasonable price not-to-exceed those quoted in this Bid for all products in the event of a disaster, emergency, or hurricane. Vendor/Contractor shall furnish a 24-hour phone number in the event of such an emergency on the Vendor Acknowledgement Form.

8) Non-Governmental Entity Human Trafficking Affidavit (§787.06(13), Fla. Stat.): The undersigned, as an officer or representative of the Vendor hereby attest, declare, and affirm that it does not use coercion for labor or services as defined in Section 787.06, Florida Statutes, effective July 1, 2024. Under penalties of perjury, Vendor declares that it has read the foregoing Vendor Acknowledgement Form and that the facts stated in it are true.

9) Acknowledgement of Addenda: Vendor hereby agrees that all addenda associated with this Solicitation Response has been acknowledged and understood that by virtue of submitting this Vendor Acknowledgement Form the Vendor has no further questions regarding the solicitation.

Vendor Acknowledgement Form BID TITLE: Cleaning Services for Grease Traps, Building and Storm Drain Lines, Lift Stations and Wastewater Tanks BID NO.: 27-02/AL

Solid Waste Authority of Palm Beach County 7501 N. Jog Road, West Palm Beach FL, 33412

Purchasing Department Senior Buyer: Angel Lopez

Telephone – 561-640-4000 x 4524

Vendor Name: Fed. ID No. or TIN:

Respondent’s Name/ Signature:

Respondent’s Title: 24-hour Emergency Telephone Number:

Mailing Address:

Street:

Toll Free Telephone Number: E-Mail Address:

City: State: ZIP: Office Number: ( )

Is Vendor a Certified Small Business Enterprise?

Yes / No Certified or Cashier's Check is attached, when required, in the amount of $