2-Forms.pdf

FORM 1

REFERENCES

The Bidders must complete this form and submit it in accordance with Section 3 of the Invitation for Bid. This form shall become an integral part of the resultant contract.

Company Name and Address

Contact Name, Telephone and Email

Work Performed Contract Cost and Duration

Rev. 6.17.22

FORM 2

CERTIFICATION OF A DRUG-FREE WORKPLACE

Section 287.087 of the Florida Statutes provides that, whenever two or more bids, proposals, or replies that are equal with respect to price, quality, and service are received by the state or by any political subdivision for the procurement of commodities or contractual services, a bid, proposal, or reply received from a business that certifies that it has implemented a drug-free workplace program shall be given preference in the award process. In order to have a drug-free workplace program, a business shall:

1) 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.

2) 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.

3) Give each employee engaged in providing the commodities or contractual services that are under Bid a copy of the statement specified in Subsection (1).

4) In the statement specified in Subsection (1), notify the employees, as a condition of working on the commodities or contractual services that are under Bid, 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.

5) 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.

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

Please sign below and return this form to certify that your business has a drug-free workplace program.

As the person authorized to sign the statement, I certify that this firm complies fully with the above requirements. False statements are punishable at law.

BIDDER /RESPONDENT COMPANY NAME:

Indicate Drug-free Workplace Program status by entering an “X” in the appropriate field:

My company DOES___ / DOES NOT ___ have an active drug-free workplace program.

Authorized Signature

Print Name and Title

FORM 3

CONFLICT OF INTEREST

Vendors are responsible for disclosing a current or reasonably foreseeable conflict of interest involving the City of Tallahassee. The City of Tallahassee seeks to avoid, neutralize or mitigate significant potential or actual organizational conflicts of interest. Respond to each of the six statements in the boxes below. Answering “Yes” will not necessarily disqualify a Vendor.

Select “Yes” if a potential conflict of interests exist or if you are uncertain whether a particular circumstance constitutes a potential conflict of interest. If ‘Yes’ is selected, you must provide an explanation on a separate document and attach to this form.

Select “No” if a potential conflict of interest does not exist.

Select “None known” only if (a) it is unduly burdensome to discover the correct response for reasons such as your workforce is so large that it is unreasonable to ascertain whether any potential conflict of interest exists and (b) you in fact do not have knowledge of any potential conflict of interest. If None Known is selected, provide an explanation on a separate document and attach to this form. The explanation must describe why it is unduly burdensome to answer Yes or No.

Yes No None Known

Potential Conflict of Interest

1. Employment by Vendor of a current City of Tallahassee employee or public official, or their family.

2. Employment by Vendor of a former City of Tallahassee public official, manager, department director.

3. Direct or indirect ownership of material personal financial interest in Vendor by a City of Tallahassee employee, public official or their family.

4. A past, present, or foreseeable payment or provision of anything of value by Vendor to a City of Tallahassee employee, public official or their family that could reasonably appear to influence the employee’s or public official’s actions or judgement.

5. An unfair competitive advantage existing in favor of Vendor with regard to a City of Tallahassee contract for which Vendor is competing. An unfair competitive advantage exists when the vendor competing for award of a contract obtained either (i) access to information that is not available to the public and which would assist the vendor in obtaining the contract or (ii) source selection information that is relevant to the contract but is not available to all competitors and that would assist the vendor in obtaining the contract.

6. Vendor, through any affiliates, subsidiaries, o other ongoing business relationships, has a potential or actual conflict between services that may be provided by Vendor to Citizens and the activities of the affiliate, subsidiary, or ongoing business relationship.

DEFINITIONS:

Authorized Representative means representative of the vendor with knowledge of vendor’s operations and personnel sufficient to in good faith provide potential conflict of interest information on behalf of the vendor as detailed above.

Relative means father, mother, son, daughter, husband, wife, brother, sister, father-in-law, mother-in- law, son-in-law or daughter-in-law, cousin, niece, nephew and stepchildren.

Material Personal Financial Interest in a vendor means any position as owner, proprietor, manager, partner (active or silent), officer, director, shareholder or beneficiary of such vendor. A material personal financial interest does not, in most instances, pertain to ownership of a limited number of shares in publicly held firms, shares owned through a mutual fund, or personal bank accounts. However, direct or indirect ownership of more than five (5) percent of the total assets or capital stock of a vendor constitutes a material personal financial interest in such vendor.

SIGNATURE: By my signature below, I certify that I am an Authorized Representative of the Vendor named below, and that all of the information provided above is true and complete to the best of my knowledge:

Print Vendor Name Print Position Title

Print Your Name Email Address and Phone Number

Signature and Date

FORM 4

REPRESENTATIONS/CERTIFICATIONS

TAXPAYER IDENTIFICATION

Respondent must complete Federal Form W-9 and submit it with their bid.

OFFICIAL COMPANY INFORMATION AS REGISTERED (Type/Print)

COMPANY NAME:

MAILING ADDRESS:

(City) (State) (Zip Code + 4)

TELEPHONE NO.:

(Toll-Free Preferred) VOICE: EXTENSION:

OTHER: FAX:

WEBSITE URL:

COMPANY CONTACT FOR CONTRACT MANAGEMENT (Type/Print)

NAME:

TELEPHONE NO.:

(Toll-Free Preferred) VOICE: EXTENSION:

OTHER: FAX:

EMAIL ADDRESS:

PAYMENT REMITTANCE ADDRESS (Type/Print)

NAME:

MAILING ADDRESS:

(City) (State) (Zip Code + 4)

TELEPHONE NO.:

(Toll-Free Preferred) VOICE: EXTENSION:

OTHER: FAX:

EMAIL ADDRESS:

CONTACT FOR INVOICE INQUIRIES

NAME:

TELEPHONE NO.:

(Toll-Free Preferred) VOICE: EXTENSION:

OTHER: FAX:

EMAIL ADDRESS:

WHERE TO SEND PURCHASE ORDER (IF APPLICABLE)

COMPANY NAME:

MAILING ADDRESS:

(City) (State) (Zip Code + 4)

EMAIL ADDRESS:

NON-COLLUSION AFFIDAVIT OF RESPONDENT

State of , County of _, being first duly sworn, deposes and says that:

1) He/She is Respondent Integrator) that has submitted the attached RFQ: of (Title) (Name of Corporation)

2) He/She is fully informed respecting the preparation and contents of the attached submittal and of all pertinent circumstances respecting such submittal.

3) Said RFQ is genuine and is not a collusive or sham RFQ.

4) Further, the said Respondent nor any of its officers, partners, owners, agents, representatives, employees or parties in interest, including this affiant, has in any way colluded, conspired, connived or agreed, directly or indirectly with any other Respondent, integrator or person to submit a collusive or sham RFQ in connection with the Contract for which the attached RFQ has been submitted or to refrain from bidding in connection with such Contract, or has in any manner, directly or indirectly, sought by agreement or collusion or communications or conference with any other Respondent, integrator or person to fix the price or prices in the attached RFQ or of any other Respondent, or to fix any overhead, profit or cost element of the RFQ price or the RFQ price of any other Respondent, or to secure through any collusion, conspiracy, connivance or unlawful agreement any advantage against the City of Tallahassee or any person interested in the proposed Contract; and

5) The price or prices quoted in the attached bid are fair and proper and are not tainted by any collusion, conspiracy, connivance, or unlawful agreement on the part of the Respondent or any ·of its agents, representatives, owners, employees, or parties in interest, including this affiant.

(Signed)

(Title)

Subscribed and sworn to before me

This day of , 2022

Notary Public (Signature)

My Commission Expires:

THIS PAGE MUST BE SUBMITTED FOR RESPONSE TO BE CONSIDERED COMPLETE AND ACCEPTABLE.

FORM 5

FORM 6

RESPONSIBLE VENDOR REVIEW FORM

A contract can only be awarded to a “responsible vendor”. A responsible vendor has the capability in all respects to fully perform the contract requirements and the integrity and reliability that will assure good faith performance.

To assist in making this determination, Vendors responding to this Solicitation are required to fully and accurately answer each of the questions below. For each “Yes” answer to questions

1.1 through 1.8, Vendor must provide a detailed explanation and attach copies of any relevant document cited in the explanation. Answering “Yes” to questions 1.1 through 1.8 will not necessarily disqualify a Vendor from participating in this Solicitation. However, failure to provide additional information as requested by the City of Tallahassee may disqualify a Vendor.

The City of Tallahassee (COT) will base its determination of a Vendor’s responsibility on: (a) information provided by Vendor in response to this form; (b) information provided elsewhere in a Vendor’s response to the Solicitation (including financial information) and (c) information obtained from independent research (including information COT obtains from the internet or third parties, including System for Award Management (SAM)).

Vendors shall provide immediate written notice to COT if any time prior to contract execution, a Vendor learns that the information provided in connection with this form was erroneous when submitted or has become erroneous for reason of changed circumstances. Vendor must contact the Procurement Officer with any questions regarding this form.

1.0 Within the last ten (10) years, in the State of Florida or any State or Federal jurisdiction has the Vendor or any of its officers, directors or owner:

1.1 Been, subject to a revocation, suspension, disbarment, administrative complaint, sanction, fine, adverse action, or disciplinary action relating to any business or professional permit, certification, and/or license?

☐ Yes

☐ No

1.2 Been suspended, debarred, or disqualified from any government contracting process or agreed to voluntary exclusion from any government procurement process?

☐ Yes

☐ No

1.3 Been subject to formal monitoring agreement or corrective action plan as part of a contract with a government entity?

☐ Yes

☐ No

1.4 Been subject to an indictment, administrative proceeding, civil action or judgment in connection with any government contract?

☐ Yes

☐ No

1.5 Had a government contract terminated for cause? ☐ Yes

☐ No

1.6 Been convicted of a crime related to governmental or

nongovernmental contracting?

☐ Yes

☐ No

1.7 Been subject to governmental investigation relating to alleged violation of any statutory regulatory violation?

☐ Yes

☐ No

1.8 Had a judgement entered in a civil lawsuit based on an allegation of fraud?

☐ Yes

☐ No

2.0 Does the vendor have the necessary organization, experience, accounting and operational controls, and professional and technical skills to meet its obligations under the proposed contract with COT, taking into consideration all existing commercial and governmental business commitments?

☐ Yes

☐ No

3.0 General Information

Do you have an active State Term Contract (STC) or General Administrative Services (GSA) Contract similar to the scope of services for this solicitation. If yes, provide an attachment with links to the contract(s)

☐ STC

☐GSA

☐ Not Applicable

By my signature below, I certify that I am an authorized representative of the Vendor named below and that all of the information provided above is true and complete to the best of my knowledge.

Name and Title Vendor Name

Signature Date

FORM 6 - Responsible Vendor Review Form