12 - Bid Submission Form.pdf

IFB 114424

BID SUBMISSION FORM

Business Identification

BUSINESS NAME:

ADDRESS:

CONTACT PERSON:

TITLE:

TELEPHONE NO.:

EMAIL ADDRESS:

REMITTANCE ADDRESS:

PROMPT PAYMENT DISCOUNT: ___% FOR PAYMENT WITHIN____ DAYS; NET___DAYS

BUSINESS ORGANIZED UNDER THE STATE LAWS OF:

PRINCIPAL BUSINESS LOCATION:

STATE CORPORATION COMMISSION IDENTIFICATION

NO.:

DUNS NUMBER:

Business Classifications

Corporation Partnership Sole Proprietor Minority Owned Small Business Non Profit Woman Owned

Ownership Disclosure

Names and address of all persons having an ownership interest of 5% or more in the business:

1.

2.

3.

Qualifications and References

Type of work performed by this business:

Number of years this business has been in operation:

Number of employees: Full time: Part Time:

Business License: Type: Issued:

Contractor’s License: Type: Class:

Issued: Expires:

List at least three state, county, or federal agencies or commercial references that the business contracted with in the past two years for a comparable procurement (include contacts and telephone numbers):

A)

B)

C)

Has the business ever defaulted or failed to complete any public body contract:

No:

Yes- Explain:

Is the entity or any of its principals currently debarred, disqualified or suspended from submitting responses to the City, or any other state, local or federal entities?

No:

Yes:

TRADE SECRETS OR PROPRIETARY INFORMATION:

Trade secrets or proprietary information submitted by the Bidder in connection with a procurement transaction shall not be subject to public disclosure under the Virginia Freedom of Information Act. However, the Bidder must identify the data and materials that need such protection prior to the submission of such data and material, and state the reasons why protection is necessary. Please mark one:

[ ] Yes, the Bid I have submitted does contain trade secrets and/or proprietary information.

[ ] No, the Bid I have submitted does not contain any trade secrets and/or proprietary information.

If Yes, Bidder must clearly identify below the exact data or other materials to be protected and list all applicable page numbers of the Bid containing such data or materials:

NOTE: If the Bidder fails to identify the data or other materials to be protected and fails to state the reasons why such protection is necessary in the space provided above, then the Bidder has not invoked protection accordingly, effectively making the Bid open for public inspection consistent with applicable law.

E THE SPECIFIC REASON(S) WHY PROTECTION IS NECESSARY:

Conflict of Interests

This solicitation is subject to the provisions of Section 2.2-3100 et. Seq., Virginia Code Annotated, the State and Local Government Conflict of Interests Act. The business is aware of information bearing on the existence of any potential organizational conflict of interest.

YES

NO

Collusion:

I certify that this bid is made without prior understanding, agreement, or connection with any corporation, firm, or person submitting a bid for the same goods and services and is in all respects fair and without collusion or fraud. I understand collusive bidding is a violation of the State and Federal law and may result in fines, prison sentences, and civil damage awards.

YES

NO

ADDENDUM RECEIVED:

The undersigned warrants that it has received the following Addendum/Addenda for the Solicitation (Show date of Addendum).

AMENDMENT NO. DATE INITIAL

[Add more as needed]

Addenda issued during the bidding period will be incorporated into the Contract Documents.

Authorized Signature

By signing this quote Business certifies, acknowledges, understands, and agrees to be bound by the conditions set forth in this Solicitation.

Authorized Signature: Date:

Name (Printed): Title:

Email Address: Telephone Number:

Submittal Documents Checklist YES NO Key Personnel (para. 12) Bid Bond Federal Forms Bid Quotation Sheet Bid Submission Form (signed) Contractors License VDOT Prequalification

State Corporation Commission Form

Virginia State Corporation Commission (SCC) registration information. The offeror:

� is a corporation or other business entity with the following SCC identification number: ____________ -

OR-

� is not a corporation, limited liability company, limited partnership, registered limited liability partnership, or business trust -OR-

� is an out-of-state business entity that does not regularly and continuously maintain as part of its ordinary and customary business any employees, agents, offices, facilities, or inventories in Virginia (not counting any employees or agents in Virginia who merely solicit orders that require acceptance outside Virginia before they become contracts, and not counting any incidental presence of the offeror in Virginia that is needed in order to assemble, maintain, and repair goods in accordance with the contracts by which such goods were sold and shipped into Virginia from offeror’s out-of-state location)

-OR-

� is an out-of-state business entity that is including with this proposal an opinion of legal counsel which accurately and completely discloses the undersigned offeror’s current contacts with Virginia and describes why those contacts do not constitute the transaction of business in Virginia within the meaning of § 13.1-757 or other similar provisions in Titles 13.1 or 50 of the Code of Virginia.

**NOTE** >> Check the following box if you have not completed any of the foregoing options but currently have pending before the SCC an application for authority to transact business in the Commonwealth of Virginia and wish to be considered for a waiver to allow you to submit the SCC identification number after the due date for proposals (the City reserves the right to determine in its sole discretion whether to allow such waiver):