2-ITN Attachment A- ITN Certification Form (Affidavit).pdf

Attachment A- ITN Certification Form (Affidavit)

Florida Polytechnic University

Respondent Information:

Company Name

Responsible Individual Name

Federal Employer Identification Number

Responsible Individual Title

Phone Number Email Address

Government Classifications. Check all that apply

☐ African American ☐ American Woman ☐ Asian-Hawaiian

☐ Government Agency ☐ Hispanic ☐ MBE Federal

☐ Native American ☐ Non-Minority ☐ Non-Profit Organization

☐ PRIDE ☐ Small Business Federal ☐ Small Business State

Bid Protest. Response tabulations with intended award(s) will be posted for review by interested parties on the Procurement Department solicitation webpage and will remain posted for a period of 72 hours. Failure to timely file a protest or failure to timely deliver the required bond or other security in accordance with the Board of Governors’ Regulations 18.002 and 18.003 is a waiver of protest proceedings.

Addenda. Please check one:

Respondent has received all Addenda issued by the University and has signed Addenda Acknowledgement Form(s) in Tab A of the Proposal.

Respondent has not received any Addenda.

Required Disclosure- Employment/Ownership. List below the names of Respondent or Respondent employees having an employment relationship with the University, State of Florida, or any Florida State Agencies, and any University or State employee(s) owning an interest of 5% or more of Respondent’s company or its affiliates or branches and describe the nature of such relationship or ownership interest. Add an additional page if needed.

Name:

Relationship/Ownership Interest:

Required Disclosure- Bankruptcy/Insolvency/Delinquency Judgement.

If Respondent has declared bankruptcy, otherwise been declared insolvent, has had a delinquency judgement issued against it in any court of competent jurisdiction, been placed in receivership, or any litigation that could significantly impact your financial operating results or financial position, provide the information below. If not, leave this section blank.

Date: Court jurisdiction:

Trustee/ Receiver Name: Phone Number:

Amount of Liabilities:

Amount of Assets:

Current Status:

Required Disclosure- Damages/Penalties/Liens/Judgments/Defaults/Cancellations/Termination.

If Respondent has had any projects within the last three years where liquidated damages, penalties, liens, judgments, defaults, cancellations of contract or termination of contract were imposed, sought to be imposed, threatened, or filed against the Respondent, provide a description below. If not, leave this section blank.

SIGNATURE REQUIRED – I hereby swear under the penalty for false swearing:

1. That I am the Respondent (if the Respondent is an individual), a partner (if the Respondent is a partnership), or an Officer or employee of the bidding corporation with authority to sign on its behalf (if the Respondent is a corporation).

2. That this proposal is made without prior understanding, agreement, or connection with any corporation, firm, or person submitting a Proposal for the same materials, supplies, equipment, or services and is in all respects fair and without collusion or fraud.

3. That the Respondent is legally entitled to enter into contracts with the Florida Polytechnic University Board of Trustees and is not in violation of any prohibited conflict of interest.

4. To abide by all conditions of this Proposal and that the Respondent is in compliance with all requirements of the ITN, including but not limited to, certification requirements.

5. In submitting a Proposal to an agency for the State of Florida, the Respondent offers and agrees that if the Proposal is accepted, the Respondent will convey, sell, assign, or transfer to the State of Florida all rights, title and interest in and to all causes of action it may now or hereafter acquire under the Anti-trust laws of the United States and the State of Florida for price fixing relating to the particular commodities or services purchased or acquired by the state of Florida. At the State’s discretion, such assignment becomes effective at the time the procurement agency tenders final payment to the Respondent.

6. That Respondent’s Proposal remains valid for six (6) months after the due date.

7. That Respondent is responsible for all travel expenses incurred for oral presentation and candidate interviews, if optional or required.

Respondent Name

By:

Signature

Printed

Title:

Printed

Date:

NO RESPONSE – If not responding to this solicitation, please advise reason and return via email to bids@floridapoly.edu with reason for NO RESPONSE