Department of Engineering and Public Works

P.O. Box 21229

West Palm Beach, FL 33416-1229

(561) 684-4000

FAX: (561) 684-4050

www.pbcgov.com

Palm Beach County Board of County Commissioners

Mack Bernard, Mayor

Dave Kerner, Vice Mayor

Hal R. Valeche

Gregg K. Weiss

Robert S. Weinroch

Mary Lou Berger

Melissa McKinlay

County Administrator

Verdenia C. Baker

"An Equal Opportunity

Affirmative Action Employer"

.;;_;;::;,,_ printed on sustainable '6¢1 and recycled paper

Date: November 7, 2019

Re: REQUEST FOR PROPOSALS

One (1) certified professional firm to provide all engineering services required for the preparation of plans and specifications complete for formal advertising and receipt of bids for:

CR 880: Sam Senter Road over SFWMD Ocean Canal

Intersection Improvements & Bridge Replacement

Project No.: 2019803

Dear Consultant:

In accordance with the enclosed Palm Beach County Notice, Prime

Consultants interested in the above referenced project are invited to attend a pre-proposal meeting and submit the documentation listed in the attached

Notice by the proposal submittal deadline.

NON-MANDATORY PRE-PROPOSAL MEETING

2300 N. Jog Road, Rm. 3W-12, West Palm Beach FL 33411

Thursday, November 21, 2019 at 11:00 a.m.

PROPOSAL SUBMITTAL DEADLINE

delivered no later than 4:00 p.m., December 10, 2019, to Roadway Production 2300 N. Jog Road, Rm. 3W-33, West Palm Beach FL 33411

The Notice and any addenda will be posted to the following website:

htt ps:/ /pbcvssp.co. palm-beach. fl. us/webapp/vssp/ AltSelfService

Questions and comments may be submitted to

Eng-RoadwayBids@pbcgov.org (please include the project number and title in the email subject line)

REQUEST FOR PROPOSALS

SUPPLEMENT AL INFORMATION TO THE NOTICE:

1. Scope of Project - The project consists of design for the replacement of the Sam Senter Road bridge over the SFWMD Ocean Canal. Realignment of CR 880 will also be required to improve the turning radii for truck traffic. Soil stabilization method of rigid inclusions will be incorporated into the design.

2. Required Summary at end of Letter of Interest - The last paragraph of the Prime consultant' s Letter of Interest (LOI) must include a summary in the format below showing the information that is provided on the prime and sub consultant questionnaires. The summary must be signed to confirm the accuracy of the attached information. All information for the summary is derived from the sign.ed Questionnaires, which must accompany the LOI.

Prime/Sub- C/SBE, Service Participation Fee

C/MBE Provided Considered Consultant TypeorC (Category#)

(For this Project) Total $ *

Prime, Inc. (>50%) C/XX(P) # % $$$$$$$

Sub-consultant # 1 C/SBE # % $$$$$$$

Sub-consultant #2 C/XX(S) # % $$$$$$$

Total Participation for the Team 100% $$$$$$$$

By signing below, signatory confirms that the above information matches the information on the attached questionnaires.

Print (Name and Title) Signature

The Fee Considered Total$ reflects the total prior work awarded to the firm by PBC, and is derived from the total in the Questionnaire.

C = CCNA Certified C/SBE = Certified CCNA & SBE C/XX = Certified CCNA & Minority (denote type)

(P) Denotes M/WBE certification with Palm Beach County

(S) denotes M/WBE certification with the State of Florida

3. Accuracy - The completeness and accuracy of information submitted is the responsibility of the prime consultant.

Project #2019803 Page 2 of 4 Date: November 7, 2019

4. Office of the Inspector General - Palm Beach County has established the Office of the Inspector General, Ordinance R2009-049, as may be amended. The Inspector General's authority includes but is not limited to the power to review past, present and proposed County contracts, transactions, accounts and records, to require the production of records, and audit, investigate, monitor, and inspect the activities of the contractor, its officers, agents, employees, and lobbyists in order to ensure compliance with contract specifications and detect corruption and fraud. All contractors and parties doing business with the County and receiving County funds shall fully cooperate with the Inspector General including receiving access to records relating to Bid or any resulting contract.

5. Policy and Procedure Manual (PPM) for CCNA Selections - PPM CW-O- 048 presents the procedure for acquisition of professional services, and is available online at:

http:// discover. pbcgov .org.tpublicaffairs/Pages/Policies-and-Procedures Manual.aspx.

This manual also includes the evaluation criteria as well as committee memberships.

6. Unrequested Services - Sub-Consultants providing services that were not requested in the Notice may be disregarded (for the unrequested services only).

7. Communication with Engineering Staff- No oral interpretation of this RFP shall be issued or considered binding. Any interpretation, clarification, correction, or change to this RFP will be made only via Addendum.

8. Addenda - As they are issued, all Addenda to this RFP will be posted under the applicable solicitation on the County's on-line Vendor Self Service (VSS).

Interpretations, corrections or changes made in any other manner will not be binding, and proposers shall not rely upon such interpretations, corrections or changes. It is the sole responsibility of the proposer to routinely check VSS for any addenda that may have been issued prior to the deadline for receipt of proposals. The County shall not be responsible for the completeness of any RFP package not downloaded from VSS.

9. County Standard Contract Required - The selected consultant will be expected to execute the County's standard contract for consulting/professional services. This document may be examined at the Engineering and Public Works Roadway Production Division office at 2300 N. Jog Road Rm 3W-33, West Palm Beach, FL 33411.

Project #2019803 Page 3 of 4 Date: November 7, 2019

10. Clarification of Responses - A response to this RFP does not constitute a bid, therefore Palm Beach County retains the right to contact any/all proposers after submittal in order to obtain supplemental information and/or clarification in either oral or written form.

Sincerely, Attachments:

1. Palm Beach County Notice

2. Proposal Forms

a. Prime Consultant Qualification Questionnaire

b. Sub-Consultant Qualification Questionnaire

c. EBO Schedule 1

d. EBO Schedule 2

e. Commercial Non-Discrimination Certification

f. Conflict of Interest Disclosure Form

g. Prime Firm's Past SBE Participation Statement

_f- \roadway\ccna\2019\2019803 sam senter\selections\rfp ads andforms\rfp package cover !etter.docx

Project #2019803 Page 4 of 4 Date: November 7, 2019

PALM BEACH COUNTY

NOTICE

Pursuant to Florida Statutes 287 .055, Notice is hereby given that Palm Beach County requires professional services on the following project:

ONE (1) CERTIFIED PROFESSIONAL FIRM TO PROVIDE:

ALL ENGINEERING SERVICES REQUIRED FOR THE PREPARATION OF PLANS AND

SPECIFICATIONS COMPLETE FOR FORMAL ADVERTISING AND RECEIPT OF BIDS FOR:

CR 880: SAM SENTER ROAD OVER SFWMD OCEAN CANAL

INTERSECTION IMPROVEMENTS & BRIDGE REPLACEMENT

PROJECT NO. 2019803

PALM BEACH COUNTY, FLORIDA.

Consultants interested in this project are required to furnish one original (bound) and one electronic version (PDF format) of their proposal no later than 4:00 P.M., December 10, 2019, with the following:

1) Letter of Interest (4 pages maximum) including reference to this Notice and a summary table.

Minimum font of 11 and minimum margins of 0.75" requested along with sufficient spacing within letter.

2) GSA Forms SF-330, to include those personnel within your firm, or sub-consultants who have expertise in the following categories:

Prime Category:

Subcategories:

3.01 (General Highway Design w/Two-Lane or Multi-Lane Rural General Free Access Highways Design).

4.01 (Minor Bridges Design).

1.07 (Environmental Studies).

5.02 (Engineering Surveying).

6.01 (Geological and Geophysical Studies).

6.06 (Materials Testing).

3) A completed Prime Consultant Qualification Questionnaire

4) A completed Sub-consultant Qualification Questionnaire (for each consultant)

5) Copy of S/M/WBE (Palm Beach County) and/or M/WBE certificate (State of Florida)

6) EBO Schedules 1 and 2

7) Commercial Non-Discrimination Certification

8) Conflict of Interest Disclosure Form

9) Prime Firm's Past SBE Participation Statement (optional)

Relevant forms may be obtained by contacting the Roadway Production Division at 561-684- 4150 or at http://discover.pbcgov.org/engineerinq/roadwayproduction/Pages/Roadway-Publications.aspx or at https://pbcvssp.co.palm-beach.fl.us/webapp/vssp/AltSelfService

Note: In accordance with Palm Beach County Code 2-351 through 2-358, "Cone of Silence" hereby applies and shall be in effect as of the deadline to submit the proposal, bid, or other response to a competitive solicitation, and is defined as the prohibition on any communication, except for written correspondence, regarding a particular Request for Proposal, Request for Qualification, bid, or any other competitive solicitation between any person or person's representative seeking an award from such competitive solicitation, and/or any County Commissioner or Commissioner's staff, or any employee authorized to act on behalf of the Commission to award a particular contract and shall terminate at the time the Board, or a County Department authorized to act on behalf of the Board, awards or approves a contract, rejects all bids or responses, or otherwise takes action which end the solicitation.

The proposals should be sent to:

Holly B. Knight, P.E., Contracts Section Manager Engineering & Public Works Department, Roadway Production Division

2300 N. Jog Road, Room 3W-33 West Palm Beach, FL 33411-27 45

Pursuant to the Palm Beach County Code Section 2-80.20 - 2-80.40 {EBO Ordinance), the County will provide contracting opportunities for S/M/WBEs in the area of professional services pursuant to Section 287.055, Florida Statutes, as amended, known as the "Consultants' Competitive Negotiation Act" (CCNA). Responses will be evaluated based on the selection criteria set out in the County's PPM# CW-O-048 and the Affirmative Procurement Initiatives (APls) determined by the County's Goal Setting Committee. The APls for this solicitation are: SBE 20% Minimum Mandatory Subcontracting Goal (Ord. 2-80.27 (3)(e)).

Project #2019803 Page 1 of 2

A Non-Mandatory Pre-Proposal Meeting will be held on Thursday, November 21, 2019 at 11:00a.m.

at the Vista Center, Conference Room 3W-12, 2300 N. Jog Rd, W. Palm Beach, FL 33411 . The purpose of the meeting is to provide a general overview of the anticipated scope of work and the anticipated typical section, and to respond to general questions about the project. It will be noted that the anticipated scope of work and typical section are not necessarily final and interested consultants are encouraged to consider other valid and appropriate options that may better suit the County's needs or reduce the project cost. Attendance at this pre-proposal meeting is highly recommended and strongly encouraged. To the extent you are unable to attend the pre-proposal meeting, you may request and obtain an audio recording of the meeting by contacting Palm Beach County Roadway Production Division at (561) 684-4150.

In addition, prior to submission of a proposal, any firm or individual, as prime consultant or as a sub consultant, desiring to provide architectural, engineering, landscape architectural, or surveying and mapping professional services to Palm Beach County must first be CCNA certified with the Roadway Production Division of the Engineering and Public Works Department as qualified pursuant to law, and in accordance with the most current administrative procedures for awarding of consulting contracts adopted by Palm Beach County.

Proposer must register in the County's Vendor Self Service (VSS) at https://pbcvssp.co.palm beach.fl.us/webapp/vssp/AltSelfService in order to be awarded a County contract. If proposer intends to use subconsultants, proposer must also ensure that all subconsultants are registered as vendors in vss.

Firms shall not add or delete team members, or adjust team participation after the proposal due date.

If a S/M/WBE team member withdraws before final selection, the respondent firm must submit a new Subconsultant's Questionnaire Form or new Schedules 1 and 2 and request a substitution from the County's Office of Equal Business Opportunity.

In accordance with F.S. 287.133 (2) (a), persons and affiliates who have been placed on the convicted vendor list may not submit bids, contract with or perform work (as a contractor, supplier, subcontractor or consultant) with any public entity (i.e. Palm Beach County) in excess of Ten Thousand Dollars (or such other amount as may be hereafter established by the Florida Division of Purchasing in accordance with F.S. 287.017) for a period of 36 months from the date of being placed on the convicted vendor list.

The County, in accordance with the provisions of Title VI of the Civil Rights Act of 1964 (78 Stat. 252, 42 U.S.C. §§ 2000d to 2000d-4) and the implementing regulations, hereby notifies all respondents that it will affirmatively ensure that any contract entered into pursuant to this advertisement, disadvantaged business enterprises will be afforded full and fair opportunity to submit proposals in response to this solicitation and will not be discriminated against on the grounds of race, color, or national origin in consideration for an award.

Any proposer may protest a notification of recommended award by submitting a written protest to the Roadway Production Division at Engineering & Public Works Department, Roadway Production Division, 2300 N. Jog Road, Room 3W-33, West Palm Beach, FL 33411-2745 within five (5) business days after the posting of the notification of recommended award by the Department.

After the notification of recommended award has been posted, any unsuccessful proposer may request a debriefing from the Roadway Production Division at Engineering & Public Works Department, Roadway Production Division, 2300 N. Jog Road, Room 3W-33, West Palm Beach, FL 33411-2745.

Palm Beach County reserves the right to reject any or all responses; to waive any or all informalities and/or irregularities; to re-advertise with either an identical or revised scope, or to cancel the solicitation in its entirety.

This Notice given this 10th day of November, 2019.

PALM BEACH COUNTY ENGINEERING & PUBLIC WORKS DEPT.

Deputy County Engineer Engineering and Public Works Department

PUBLISH: THE PALM BEACH POST

SUNDAY: November 10, 2019

November 17, 2019

Project #2019803 Page 2 of 2

PRIME CONSULTANT QUALIFICATION QUESTIONNAIRE

The detailed data requested here must be submitted in this format only.

Use as many pages as needed to provide the following required information:

PRIME CONSULTANT

Firm Name: ___________________________________________________________________

Office Location: ________________________________________________________________ Street Address State Zip Code

Contact Person: ______________________________ Title: ___________________________

Contact Person Email: ___________________________________________________________

Telephone No: __________________ Fax No: _______________ No. of Employees _______

The undersigned intends to perform work in connection with the above project as (check one):

An individual A corporation A partnership A joint venture

S/M/WBE Certifications: Check all that apply and attach applicable copy of certification letter(s) or certificate(s). Certifications must be valid on RFP or other type of submittal due date.

S/M/WBE (certified with Palm Beach County) Asian Black Caucasian Hispanic Other _______ Male Female

M/WBE (certified with State of FL) Asian Black Caucasian Hispanic Other _______ Male Female

Project Name: ________________________________________________________________

Project No.: _________________________

Scope of Service _______________________________________________________________

(1) __________% Prime Consultant’s “Total Project Participation (TPP)” (Note: Line 1 shall reflect the ACTUAL % and must be less than 100%)

(2) __________% Prime Consultant’s TPP performed in Palm Beach County office(s)

(3) __________% Prime Consultant’s TPP performed outside of Palm Beach Co. office(s) (Note: Line 2 plus Line 3 must equal Line 1)

PRIME CONSULTANT QUALIFICATION QUESTIONNAIRE

Dollar Volume Award:

List all projects with associated contract and supplement fees awarded by the Palm Beach County Board of County Commissioners in the fiscal years (October 1 to September 30) indicated.

FY Period **Firm’s Fee Factor Fee Considered

(1) Current Fiscal Year: $_________________ x 1.00 = $_____________________

(2) Previous Fiscal Year: $_________________ x 0.75 = $_____________________

(3) Fiscal Year Once Removed: $_________________ x 0.50 = $_____________________

(4) Fiscal Year Twice Removed:$_________________ x 0.25 = $_____________________

Total: $_________________________________

** Palm Beach County fees rendered to consultant, minimum fees subcontracted out by consultant to sub-consultant. Fees for which the consultant is a sub-consultant shall be included.

Prime Consultant Firm: ________________________________________________________

Signature: _____________________________________

Date: _________________________________________

Title: _________________________________________

SUB-CONSULTANT QUALIFICATION QUESTIONNAIRE

The detailed data requested here must be submitted in this format only.

Use as many pages as needed to provide the following required information:

SUB-CONSULTANT

Firm Name: ___________________________________________________________________

Office Location: ________________________________________________________________ Street Address State Zip Code

Contact Person: _______________________________ Title: __________________________

Contact Person Email: ___________________________________________________________

Telephone No: ___________________ Fax No: _______________ No. of Employees _______

The undersigned intends to perform work in connection with the above project as (check one):

An individual A corporation A partnership A joint venture

S/M/WBE Certifications: Check all that apply and attach applicable copy of certification letter(s) or certificate(s). Certifications must be valid on RFP or other type of submittal due date.

S/M/WBE (certified with Palm Beach County) Asian Black Caucasian Hispanic Other _______ Male Female

M/WBE (certified with State of FL) Asian Black Caucasian Hispanic Other _______ Male Female

Name of Prime Consultant: ______________________________________________________

Project Name: ________________________________________________________________

Project No.: _________________________

Scope of Service _______________________________________________________________

(1) __________% Subconsultant’s “Total Project Participation (TPP)” (Note: Line 1 shall reflect the ACTUAL % and must be less than 100%)

(2) __________% Subconsultant’s TPP performed in Palm Beach County office(s)

(3) __________% Subconsultant’s TPP performed outside of Palm Beach Co. office(s) (Note: Line 2 plus Line 3 must equal Line 1)

Dollar Volume Award:

List all projects with associated contract and supplement fees awarded by the Palm Beach County Board of County Commissioners in the fiscal years (October 1 to September 30) indicated.

FY Period **Firm’s Fee Factor Fee Considered

(1) Current Fiscal Year: $__________________ x 1.00 = $______________________

(2) Previous Fiscal Year: $__________________ x 0.75 = $______________________

(3) Fiscal Year Once Removed: $__________________ x 0.50 = $______________________

(4) Fiscal Year Twice Removed: $__________________ x 0.25= $______________________

Total: $ _______________________________

** Palm Beach County fees rendered to consultant, minimum fees subcontracted out by consultant to sub-consultant. Fees for which the consultant is a sub-consultant shall be included.

USER DEPARTMENT INFORMATION

Subconsultant Firm: __________________________________________________________

Signature: _____________________________________

Date: _________________________________________

Title: _________________________________________

REVISED 02/28/2019

OEBO SCHEDULE 1

LIST OF PROPOSED CONTRACTOR/CONSULTANT AND SUBCONTRACTOR/SUBCONSULTANT PARTICIPATION

SOLICITATION/PROJECT/BID NAME: _________________________________________ SOLICITATION/PROJECT/BID No.: ______________________________________

NAME OF PRIME RESPONDENT/BIDDER: ADDRESS: _________________________________________________________

CONTACT PERSON: _______________________________________________________ PHONE NO.: ___________________________ E-MAIL:______________________

SOLICITATION OPENING/SUBMITTAL DATE: ___________________________________ DEPARTMENT: ______________________________________________________

PLEASE LIST THE DOLLAR AMOUNT OR PERCENTAGE OF WORK TO BE COMPLETED BY THE PRIME CONTRACTOR/CONSULTANT ON THIS PROJECT.

PLEASE ALSO LIST THE DOLLAR AMOUNT OR PERCENTAGE OF WORK TO BE COMPLETED BY ALL SUBCONTRACTORS/SUBCONSULTANTS ON THE

PROJECT.

(Check all Applicable Categories) Non-SBE M/WBE SBE DOLLAR AMOUNT OR PERCENTAGE OF WORK

Name, Address and Phone Number Minority/Women Small

Business Business Black Hispanic Women Caucasian Other (Please Specify)

1.

2.

3.

4.

5.

(Please use additional sheets if necessary) Total ___ _____ __ ______ _________ _________ _________

Total Bid Price $________________________________________ Total SBE - M/WBE Participation _____________

I hereby certify that the above information is accurate to the best of my knowledge: ____________________________________________________________ ______________________________________ Signature Title

Note: 1. The amount listed on this form for a Subcontractor/subconsultant must be supported by price or percentage listed on the properly executed Schedule 2 or attached signed proposal.

2. Firms may be certified by Palm Beach County as an SBE and/or an M/WBE. If firms are certified as both an SBE and/or M/WBE, please indicate the dollar amount under the appropriate category.

3. Modification of this form is not permitted and will be rejected upon submittal.

Revised 09/17/2019

OEBO LETTER OF INTENT – SCHEDULE 2

A completed Schedule 2 is a binding document between the Prime Contractor/consultant and a Subcontractor/subconsultant (for any tier) and should be treated as such. The Schedule 2 shall contain bolded language indicating that by signing the Schedule 2, both parties recognize this Schedule as a binding document. All Subcontractors/subconsultants, including any tiered Subcontractors/subconsultants, must properly execute this document. Each properly executed Schedule 2 must be submitted with the bid/proposal.

SOLICITATION/PROJECT NUMBER: _2019803________________________________________________________________________

SOLICITATION/PROJECT NAME: CR 880: Sam Senter Rd. over SFWMD Ocean Canal Intersection Improvements & Bridge Replacement

Prime Contractor: ___________________________________________Subcontractor:______________________________________ (Check box(s) that apply) � SBE � WBE � MBE � M/WBE � Non-S/M/WBE Date of Palm Beach County Certification (if applicable):_______________.

The undersigned affirms they are the following (select one from each column if applicable):

Column 1 Column 2 Column 3

� Male � Female � African-American/Black � Asian American � Caucasian American � Supplier � Hispanic American � Native American

S/M/WBE PARTICIPATION – S/M/WBE Primes must document all work to be performed by their own work force on this form. Failure to submit a properly executed Schedule 2 for any S/M/WBE participation may result in that participation not being counted. Specify in detail, the scope of work to be performed or items supplied with the dollar amount and/or percentage for each work item. S/M/WBE credit will only be given for the areas in which the S/M/WBE is certified. A detailed proposal may be attached to a properly executed Schedule 2.

Line Item

Item Description Unit Price Quantity/ Units

Contingencies/ Allowances

Total Price/Percentage

The undersigned Subcontractor/subconsultant is prepared to self-perform the above-described work in conjunction with the aforementioned project at the following total price or percentage:

Print Name of Prime Print Name of Subcontractor/subconsultant

By: _____________________________________________ By: ________________________________________________ Authorized Signature Authorized Signature

Print Name Print Name

Title Title

Date: ___________________________________________ Date: ______________________________________________

If the undersigned intends to subcontract any portion of this work to another Subcontractor/subconsultant, please list the business name and the amount below accompanied by a separate properly executed Schedule 2.

Price or Percentage:

Name of 2nd/3rd tier Subcontractor/subconsultant f:\roadway\ccna\2019\2019803 sam senter\selections\rfp ads and forms\commercial non-discrimination.docx

PALM BEACH COUNTY COMMERCIAL NON-DISCRIMINATION CERTIFICATION

CR 880: Sam Senter Road over SFWMD Ocean Canal

Intersection Improvements & Bridge Replacement

PROJECT # 2019803

The undersigned Proposer hereby certifies and agrees that the following information is correct:

In preparing its response to this Solicitation, the Proposer has considered all proposals submitted from qualified, potential Subconsultants/Subcontractors and suppliers, and has not engaged in "discrimination" as defined in the

County’s Commercial Nondiscrimination Policy as set forth in Resolution 2017-1770 as amended, to wit:

discrimination in the solicitation, selection or commercial treatment of any Subconsultant/Subcontractor, vendor, supplier or commercial customer on the basis of race, color, national origin, religion, ancestry, sex, age, marital status, familial status, sexual orientation, gender identity or expression, disability, or genetic information, or on the basis of any otherwise unlawful use of characteristics regarding the vendor's, supplier's or commercial customer's employees or owners; provided that nothing in this policy shall be construed to prohibit or limit otherwise lawful efforts to remedy the effects of discrimination that have occurred or are occurring in the County’s relevant marketplace of Palm Beach County. Without limiting the foregoing, "discrimination" also includes retaliating against any person or other entity for reporting any incident of "discrimination."

Without limiting any other provision of the solicitation, it is understood and agreed that, if this certification is false, such false certification will constitute grounds for the County to reject the proposal submitted by the

Proposer for this Solicitation, and to terminate any contract awarded based on the response.

As part of its proposal, the Proposer shall provide to the County a list of all instances within the immediate past four (4) years where there has been a final adjudicated determination in a legal or administrative proceeding in the State of Florida that the Proposer discriminated against its Subconsultants/Subcontractors, vendors, suppliers or commercial customers, and a description of the status or resolution of that complaint, including any remedial action taken.

As a condition of submitting a proposal to the County, the Proposer agrees to comply with the County’s

Commercial Nondiscrimination Policy as described in Resolution 2017-1770 as amended.

PROPOSAL PROVIDED BY: _____________

Firm Name

(Print Name and Title) (Signature) (Date)

CONFLICT OF INTEREST DISCLOSURE FORM

Project: CR 880: Sam Senter Road over SFWMD Ocean Canal Intersection Improvements &

Bridge Replacement

Project No.: 2019803

CONSULTANT/ANNUAL CONSULTANT represents that it presently has no interest, either direct or indirect, which would or could conflict in any manner with the performance of services for the County, except as follows:

(Attach additional sheets as needed)

CONSULTANT/ANNUAL CONSULTANT further represents that it presently has no interest and shall acquire no interest which would conflict with performance of services solicited herein, as provided for in Chapter 112, Part III, Florida Statutes, and Section 2-441, et seq., the Palm Beach County Code of Ethics. The CONSULTANT/ANNUAL CONSULTANT further represents that no person having any such conflict of interest shall be employed for said performance of services.

CONSULTANT/ANNUAL CONSULTANT shall promptly notify the COUNTY in writing by certified mail of all potential conflicts of interest that may arise in the future through any prospective business association, interest or other circumstance which may influence or appear to influence CONSULTANT’S/ANNUAL CONSULTANT’S judgment or quality of services being provided to the County. Such written notification shall identify the prospective business association, interest or circumstance, the nature of work that CONSULTANT/ANNUAL CONSULTANT may undertake and request an opinion of the COUNTY as to whether the association, interest or circumstance would, in the opinion of the COUNTY, constitute an unacceptable conflict of interest if entered into by the CONSULTANT/ANNUAL CONSULTANT.

If, in the sole opinion of the COUNTY, the prospective business association, interest or circumstance of CONSULTANT/ANNUAL CONSULTANT would constitute an unacceptable conflict of interest to the COUNTY, the COUNTY shall so state in the notification and the CONSULTANT/ANNUAL CONSULTANT shall not enter into said association, interest or circumstance.

By signing below, CONSULTANT/ANNUAL CONSULTANT certifies that the information contained herein is true and correct and constitutes all current potential conflicts of interest which may influence or appear to influence CONSULTANT’S/ANNUAL CONSULTANT’S judgment or quality of services being provided to the County.

THIS DISCLOSURE is submitted by , as , of .

who hereby certifies that the information stated above is true and correct. Further, it is hereby acknowledged that any misrepresentation by the CONSULTANT/ANNUAL CONSULTANT on this Disclosure is considered an unethical business practice and is grounds for sanctions against future County business with the

CONSULTANT/ANNUAL CONSULTANT.

(Print Name and Title) (Signature) (Date)

F:\ROADWAY\CCNA\2019\2019803 Sam Senter\Selections\RFP Ads and Forms\Conflict of Interest (if applicable).docx

PRIME FIRM’S PAST SBE PARTICIPATION STATEMENT

f:\roadway\ccna\2019\2019803 sam senter\selections\rfp ads and forms\prime firms sbe past participation statement.docx

SBE and/or M/WBE Participation County Contracts Completed (Prior 12 Months) Committed (%) Achieved (%)

For any County contracts completed in the prior 12 months that did not meet the committed SBE participation, an explanation for the shortfall may be provided below. Please note that submittal of this form is optional.

Firm Name Name of Individual

Signature Date

Roadway Production Division 2300 N. Jog Road Room 3W-33 West Palm Beach, FL 33411

Roadway Production Division 2300 N. Jog Road Room 3W-33 West Palm Beach, FL 33411