12-Vendor Questionnaire and Standard Certifications - RFP-RFQ-RLI.docx

VENDOR QUESTIONNAIRE AND STANDARD CERTIFICATIONS

REQUEST FOR PROPOSAL, REQUEST FOR QUALIFICATION, OR REQUEST FOR LETTER OF INTEREST

The completed form, including standard certifications, should be submitted with the solicitation response. If a response requires additional information, the Vendor should upload a written detailed response with submittal; each response should be labeled to match the question number.

If not submitted with solicitation response, it must be submitted within three business days after County's written request. Failure to timely submit may affect Vendor's evaluation.

1. Legal business name: Click or tap here to enter text.

2. Doing Business As/Fictitious Name (if applicable): Click or tap here to enter text.

3. Federal Employer I.D. No. (FEIN): Click or tap here to enter text.

4. Dun and Bradstreet No.: Click or tap here to enter text.

5. Website address (if applicable): Click or tap here to enter text.

6. Principal place of business address: Click or tap here to enter text.

7. Office location responsible for this project: Click or tap here to enter text.

8. Telephone No.: Click or tap here to enter text. Fax No.: Click or tap here to enter text.

9. Generic e-mail for purchase orders: Click or tap here to enter text.

(Broward County auto distributes purchase orders; to ensure Vendor receives purchase orders, a company accessible e-mail address is suggested.)

10. Type of business (check appropriate box):

☐ Corporation (specify the state of incorporation) Click or tap here to enter text.

☐ Sole Proprietor ☐ Limited Liability Company (LLC) ☐ Limited Partnership ☐ General Partnership ☐ Other – Specify: Click or tap here to enter text.

11. Authorized Contact(s):

12. List name and title of each principal, owner, officer, and majority shareholder:

For Questions 13 – 18, if any answer is “Yes”, specify details in an attached written response with submittal; each response should be labeled to match the question number.

13. Is Vendor or any of its principals or officers currently a principal or officer of another organization?

☐ Yes ☐ No

14. Has Vendor, or any of its principals, officers, or predecessor organization(s), been debarred or suspended by any government entity within the last three years? ☐ Yes ☐ No

15. Has Vendor ever failed to complete any services and/or delivery of products during the last three years?

☐ Yes ☐ No

16. Have any voluntary or involuntary bankruptcy petitions been filed by or against Vendor, its parent or subsidiaries or predecessor organizations during the last three years? ☐ Yes ☐ No

17. Has Vendor’s surety ever intervened to assist in the completion of a contract or have Performance and/or Payment Bond claims been made to Vendor’s or its predecessor’s sureties during the last three years?

☐ Yes ☐ No

18. Has Vendor been terminated from a contract within the last three years? ☐ Yes ☐ No

19. Participation in Solicitation Development: By submission of this solicitation response, the Vendor certifies as follows (select one):

☐ I have not participated in the preparation or drafting of any language, scope, or specification that would provide my firm or any affiliate an unfair advantage of securing this solicitation.

☐ I have provided information regarding the specifications and/or products listed in this solicitation. If this box is checked, provide the following:

Name of Person the information was provided to: Click or tap here to enter text.

Title: Click or tap here to enter text.

Date information provided: Click or tap here to enter text.

For what purpose was the information provided? Click or tap here to enter text.

Standard Certifications:

Drug-Free Workplace Certification In accordance with Section 287.087, Florida Statutes, whenever two or more submittals are tied, a submittal received from a Vendor that certifies it has implemented a drug-free workplace program shall be given preference in the award process.

The Vendor hereby certifies that: (only if Vendor is certifying it currently complies, check box)

☐ The Vendor hereby certifies that it has established a drug-free workplace program in accordance with the requirements of Section 287.087, Florida Statutes, (“Preference to businesses with drug-free workplace programs.”)

Non-Collusion Certification Vendor shall disclose, to their best knowledge, any Broward County officer or employee, or any relative of any such officer or employee as defined in Section 112.3135 (1) (c), Florida Statutes, who is an officer or director of, or has a material interest in, the Vendor's business, who is in a position to influence this procurement. Any Broward County officer or employee who has any input into the writing of specifications or requirements, solicitation of offers, decision to award, evaluation of offers, or any other activity pertinent to this procurement is presumed, for purposes hereof, to be in a position to influence this procurement. Failure of a Vendor to disclose any relationship described herein shall be reason for debarment in accordance with the provisions of the Broward County Procurement Code.

The Vendor hereby certifies that: (select one)

☐ The Vendor certifies that this offer is made independently and free from collusion; or

☐ The Vendor is disclosing names of officers or employees who have a material interest in this procurement and is in a position to influence this procurement. Vendor must include a list of name(s), and relationship(s) with its submittal.

Public Entities Crimes Certification In accordance with Public Entity Crimes, Section 287.133, Florida Statutes, a person or affiliate placed on the convicted vendor list following a conviction for a public entity crime may not submit on a contract: to provide any goods or services; for construction or repair of a public building or public work; for leases of real property to a public entity; and may not be awarded or perform work as a contractor, supplier, subcontractor, or consultant under a contract with any public entity; and may not transact business with any public entity in excess of the threshold amount provided in s. 287.017 for Category Two for a period of 36 months following the date of being placed on the convicted vendor list.

The Vendor hereby certifies that: (check box)

☐ The Vendor certifies that no person or affiliates of the Vendor are currently on the convicted vendor list and/or has not been found to commit a public entity crime, as described in the statutes.

Scrutinized Companies List Certification Pursuant to Section 287.135, Florida Statutes, any company or other entity on the Scrutinized Companies with Activities in Sudan List, the Scrutinized Companies with Activities in Iran Terrorism Sectors List, or the Scrutinized Companies or Other Entities that Boycott Israel List, are prohibited from bidding on, submitting a proposal for, or entering into or renewing a contract with an agency or local governmental entity for goods or services of (a) $100,000 or more if, at the time of bidding on, submitting a proposal for, or entering into or renewing such contract, the company or other entity is on the Scrutinized Companies or Other Entities that Boycott Israel List, created pursuant to Section 215.4725, Florida Statutes, or is engaged in a boycott of Israel; or (b) $1,000,000 or more if, at the time of bidding on, submitting a proposal for, or entering into or renewing such contract, the company or other entity is on the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in Iran Terrorism Sectors List, created pursuant to Section 215.473, Florida Statutes; or is engaged in business operations in Cuba or Syria.

The Vendor hereby certifies that: (check each box)

☐ The company or other entity is aware of the above cited requirements of Sections 287.135215.473, and 215.4725, Florida Statutes, regarding the above cited lists; and

☐ The company or other entity is eligible to participate in this solicitation and are not listed on the cited lists above; and

☐ If awarded the Contract, the company or other entity will immediately notify the County in writing if it is placed on the above cited lists.

I hereby certify the information provided in this Vendor Questionnaire and Standard Certifications is true and correct*:

Vendor Name: Click or tap here to enter text.

Signature: ______________________________ Printed Name: Click or tap here to enter text.

Title: Click or tap here to enter text.

Date: Click or tap to enter a date.

* I certify that I am authorized to sign this solicitation response on behalf of the Vendor as indicated in Certificate as to Corporate Principal, designation letter by Director/Corporate Officer, or other business authorization to bind on behalf of the Vendor. As the Vendor's authorized representative, I attest that any and all statements, oral, written or otherwise, made in support of the Vendor's response, are accurate, true and correct. I also acknowledge that inaccurate, untruthful, or incorrect statements made in support of the Vendor's response may be used by the County as a basis for rejection, rescission of the award, or termination of the contract and may also serve as the basis for debarment of Vendor pursuant to PART XI of the Broward County Procurement Code. I certify that the Vendor's response is made without prior understanding, agreement, or connection with any corporation, firm or person submitting a response for the same items/services, and is in all respects fair and without collusion or fraud. I also certify that the Vendor agrees to abide by all terms and conditions of this solicitation, acknowledge and accept all of the solicitation pages as well as any special instructions sheet(s).

Form Date 10/10/25