1412207679 Appendix B - Response Forms.pdf

1412207679 Appendix B - Response Forms

ITN Hydrated Ash Hauling and Disposal

Submit the Response an electronic PDF in accordance with the procedures in the solicitation

Company Name:

Company’s Address:

License Number:

Phone Number: FAX No: Email Address:

BID SECURITY REQUIREMENTS TERM OF CONTRACT

None required One Time Purchase Certified Check or Bond Five Percent (5%) Term

Other, Specify - Project Completion

SAMPLE REQUIREMENTS SECTION 255.05, FLORIDA STATUTES CONTRACT BOND

None required None required Samples required prior to Bid Opening Bond required 100% of Bid Award Samples may be required subsequent to

Bid Opening

QUANTITIES INSURANCE REQUIREMENTS

Quantities indicated are exacting Quantities indicated reflect the approximate quantities to be purchased Insurance required

Throughout the Contract period and are subject to fluctuation in accordance with actual requirements.

PAYMENT DISCOUNTS

1% 20, net 30 CONTACT INFO FOR PROCESSING PURCHASE ORDERS 2% 10, net 30 Other Name: _____________________ Email: ______________________ None Offered

Item

No. ENTER YOUR BID FOR THE FOLLOWING DESCRIBED ARTICLES OR SERVICES: TOTAL BID PRICE

1 Fuel Surcharge (Cell C6 from Response Workbook) $_______________

3 Total Turnkey Price (Cell E17 of the Response Workbook) $_______________

I have read and understood the Sunshine Law/Public Records clauses contained within this solicitation. I understand that in the absence of a redacted copy my proposal will be disclosed to the public “as-is”.

BIDDER CERTIFICATION

By submitting this Bid, the Bidder certifies that it has read and reviewed all of the documents pertaining to this Solicitation, that the person signing below is an authorized representative of the Bidding Company, that the Company is legally authorized to do business in the State of Florida, and that the Company maintains in active status an appropriate contractor’s license for the work (if applicable).

The Bidder also certifies that it complies with all sections (including but not limited to Conflict Of Interest and Ethics) of this Solicitation.

We have received addenda Handwritten Signature of Authorized Officer of Company or Agent Date

_______ through _______

Printed Name and Title

THE MINIMUM QUALIFICATIONS SHALL BE SUBMITTED ON THIS FORM. IN ORDER TO BE CONSIDERED A

QUALIFIED BIDDER BY JEA YOU MUST MEET THE MINIMUM QUALIFICATIONS LISTED BELOW, AND BE

ABLE TO PROVIDE ALL THE SERVICES LISTED IN THIS SOLICITATION.

THE BIDDER MUST COMPLETE THE BIDDER INFORMATION SECTION BELOW AND PROVIDE ANY OTHER

INFORMATION OR REFERENCE REQUESTED. THE BIDDER MUST ALSO PROVIDE ANY ATTACHMENTS

REQUESTED WITH THIS MINIMUM QUALIFICATIONS FORM.

BIDDER INFORMATION

COMPANY NAME:

BUSINESS ADDRESS:

CITY, STATE, ZIP CODE:

TELEPHONE:

FAX:

E-MAIL:

PRINT NAME OF AUTHORIZED REPRESENTATIVE:

SIGNATURE OF AUTHORIZED REPRESENTATIVE:

NAME AND TITLE OF AUTHORIZED REPRESENTATIVE:

MINIMUM QUALIFICATIONS:

Respondent must meet the following Minimum Qualifications to be considered eligible to have its Response evaluated by JEA. Respondent must complete and submit the Minimum Qualification Form provided in this Solicitation. Respondents that are working or have worked for JEA in the past 2 years involving similar work must submit JEA as a reference. JEA reserves the right to ask for additional back up documentation or additional reference projects to confirm the Respondent meets the requirements stated below.

JEA may reject Responses from Respondents not meeting all of the following Minimum Qualifications:

I. The Respondent must have successfully performed similar work preceding the Response Due Date.

II. The Respondent will adhere to the Minimum Qualifications as outlined in Appendix A -Technical

Specifications III. The Respondent is not on the State of Florida Convicted Vendor List, State of Florida’s

Suspended Vendor List, The City of Jacksonville’s Disqualified Vendor List, have not had their bidding privileges actively suspended by JEA, been debarred by JEA, or have had a contract with JEA terminated for default within the last two (2) years.

REFERENCE 1 of 3

Reference Name_________________________________________________________________________________

Reference Phone Number _________________________________________________________________________

Reference Company Name _________________________________________________________________________

Address of Work _________________________________________________________________________________

Reference E-Mail Address __________________________________________________________________________

Dates of Work/$ Amount ___________________________________________________________________________

Description of Work _______________________________________________________________________________

REFERENCE 2 of 3

Reference Phone Number _________________________________________________________________________

Reference Company Name _________________________________________________________________________

Address of Work _________________________________________________________________________________

Reference E-Mail Address __________________________________________________________________________

Dates of Work/$ Amount ___________________________________________________________________________

Description of Work _______________________________________________________________________________

REFERENCE 3 of 3

Reference Phone Number _________________________________________________________________________

Reference Company Name _________________________________________________________________________

Address of Work _________________________________________________________________________________

Reference E-Mail Address __________________________________________________________________________

Dates of Work/$ Amount ___________________________________________________________________________

Description of Work _______________________________________________________________________________

VENDOR CONFLICT OF INTEREST DISCLOSURE FORM INSTRUCTIONS

Vendors shall not try to gain an unfair competitive advantage or influence the ability of JEA officers and employees to make impartial and objective decisions on behalf of JEA.

All vendors interested in conducting business with JEA must complete and return the Vendor Conflict of

Interest Disclosure Form found on the following page in order to be eligible to be awarded a contract with JEA.

Please note that all vendors are subject to comply with JEA’s conflict of interest policies provided below.

1. No JEA officer (e.g., JEA Board member and elected City official) or employee has an ownership interest of more than 5% in vendor’s company.

2. No JEA officer or employee is an officer, director, partner or proprietor of vendor’s company.

3. No JEA officer or employee is employed by or being considered for employment by vendor’s company.

4. No JEA officer or employee work as a consultant or has a contractual relationship with vendor’s company.

5. No JEA officer or employee will derive a personal financial gain or loss from this contract.

6. No relative of a JEA officer of employee will derive a personal financial gain or loss from this contract. (Relatives include a father, mother, son, daughter, husband, wife, brother, sister, father-in-law, mother-in-law, son-in-law, or daughter-in-law.)

If a vendor has one or more relationships with a JEA officer or employee or a relative of a JEA officer or employee that meets the criteria described above, then the vendor shall disclose the information by completing the Conflict of Interest Form on the following page.

CONFLICT OF INTEREST DISCLOSURE FORM

Disclosing a potential conflict of interest does not disqualify vendors. In the event vendors do not disclose potential conflicts of interest, and they are detected by JEA, vendor may be disqualified from doing business with JEA.

Questions about this form? Contact (JEA, Buyer)

JEA Bid/Solicitation/Contract Number:

Name of JEA Employee(s) Working on Vendor’s Current Contract(s) with JEA:

Vendor Name:

Vendor Phone:

Vendor’s Authorized Representative Name and Title: Authorized Representative’s Phone:

NAME(S) OF JEA EMPLOYEE(S) / PUBLIC OFFICER(S) WITH POTENTIAL CONFLICT OF INTEREST

Name of JEA public officer(s), employee(s), or relatives with whom there may be a potential conflict of interest. If more than five, attach a second form.

Relationship of JEA public officer(s)/employee(s) and/or relative(s) to vendor’s company from list above (e.g. 1(a), 2, etc.). Please list all that apply:

1.

2.

3.

4.

5.

□ Vendor has no conflict of interest to report.

□ Vendor hereby declares it has not and will not provide gifts or hospitality of any dollar value or any other gratuities to any JEA officer or employee to obtain or maintain a contract.

□ I certify that this Conflict of Interest Disclosure has been examined by me and that its contents are true and correct to my knowledge and belief and I have the authority to so certify on behalf of the Vendor.

Vendor’s Authorized Representative Signature: Date:

https://www.jea.com/

FOR JEA USE ONLY IF CONFLICT NOTED

This form has been reviewed by:

Name of JEA Ethics Officer: Signature: Date:

Note: