3-1 Certifications and Supplemental Forms.pdf

CERTIFICATIONS AND REPRESENTATIONS

M/WBE STATUS

___________________________________________________ IS CERTIFIED AS A:

(CHECK ONE, IF APPLICABLE)

DISADVANTAGED BUSINESS ENTERPRISE ___________

MINORITY-OWNED BUSINESS ENTERPRISE ___________

WOMEN-OWNED BUSINESS ENTERPRISE ___________

PLEASE ATTACH OFFICIAL DOCUMENTATION FROM THE STATE OF TEXAS OR OTHER

QUALIFIED CERTIFICATION AGENCY OF M/WBE STATUS OF YOUR COMPANY WITH YOUR

RESPONSE TO THIS ITB/RFQ/RFP.

* * * * * NOTE * * * * *

THIS DATA IS REQUESTED FOR INFORMATIONAL PURPOSES ONLY AND WILL NOT AFFECT

THE ITB/RFQ/RFP AWARD.

(SUBMISSION OF THIS INFORMATION IS NOT A REQUIREMENT.)

CERTIFICATION OF NON-DISCRIMINATION

A. The Contractor (successful Bidder) and/or any subcontractor(s), if permitted, certifies complete compliance with the Federal Civil Rights Law and the Americans with Disabilities Act, agreeing to non-discrimination based on race, age, color, religion, disability, gender, ancestry, national origin, or place of birth in employment practices, programs and services. These practices, programs, and services shall include, but not be limited to, the following: employment, upgrading, demotion or transfer; recruitment or recruitment advertising; layoff or termination; rates of pay or other compensation; and selection for training, including apprenticeship.

B. The Contractor shall in all solicitations or advertisements for employees placed by or on behalf of the Contractor, state that all qualified applicants will receive consideration for employment without regard to race, age, color, religion, disability, gender, ancestry, national origin, or place of birth.

C. Upon request by the City, the Contractor shall furnish all information or reports required to investigate his/her payrolls and personnel records, which pertain to current contract(s) with the City for purposes of ascertaining compliance with this non-discrimination certification.

CERTIFICATION OF INDEPENDENT PRICE DETERMINATION

By submission of a response to this ITB, the Bidder certifies, and in the case of a joint offer, each party thereto certifies as to its own organization, that in connection with this procurement:

A. The prices in this response to this ITB have been arrived at independently, without consultation, communication, or agreement, for the purpose of restricting competition, as to any matter relating to such prices with any other Bidder or with any competitor;

B. Unless otherwise required by law, the prices which have been bid herein have not knowingly been disclosed by the Bidder and will not knowingly be disclosed by the Bidder prior to opening of ITB responses, directly or indirectly to any other Bidder or competitor; and

C. No attempt has been made by the Bidder to induce any other person or firm to submit or not to submit an ITB response for the purpose of restricting competition.

BID CERTIFICATION

The undersigned hereby certifies that he/she has read, understands and agrees that acceptance by the City of the Bidder's offer by issuance of a purchase order will create a binding contract. Furthermore, he/she agrees to fully comply with documentary forms herewith made a part of this specific procurement.

NAME OF COMPANY

AUTHORIZED SIGNATURE

ADDRESS

CITY AND STATE ZIP

PHONE NUMBER

DATE

OUT OF STATE CERTIFICATION

As defined by Section 2252.001 of the Texas Government Code, a “nonresident Bidder/Proposer” means a Bidder/Proposer whose principal place of business is not in Texas but excludes a contractor whose ultimate parent company or majority owner has its principal place of business in Texas.

( ) I certify that my company is a “Resident Bidder/Proposer”:

Company Name

( ) I certify that my company qualifies as a “Non-Resident Bidder/Proposer”

(Note: You must furnish the following information)

Indicate the following information for your “Resident State” (the state in which your principal place of business is located):

Company Name Address

City State Zip

A. Does your “resident state” require Bidders whose principal place of business is in Texas to underprice Bidders whose resident state is the same as yours by a prescribed amount or percentage to receive a comparable contract?

( ) Yes

( ) No

B. What is the prescribed amount or percentage?

$ or %

By signature below, I certify that the above is true and correct and that I am authorized by my company to make such certifications.

Company Name

Signature of Authorized Company Official Date

BIDDER SUPPLEMENTAL INFORMATION

Name of Company:

Indicate the state by which your business is governed:

Is the company a:

Sole Proprietorship Yes _____ No _____

General Partnership Yes _____ No _____

Limited Partnership Yes _____ No _____

Corporation Yes _____ No _____

Other:

Year the company was established and former names of the company, if applicable.

If the company is a sole proprietorship, please list the owner’s full legal name, the name under which business is conducted (i.e. d/b/a), the address for the company, including the state and county in which your business is located:

If the company is a general partnership, please list the exact name of the partnership, whether it is a partnership formed under the laws of the State of Texas or another state, the business address for the partnership, including the state and county, and list of the names of all of the partners for the partnership:

If the company is a limited partnership, please list the exact name of the limited partnership, whether it is a limited partnership formed under the laws of the State of Texas or another state, the business address for the limited partnership, including the state and county, and list the names of all the general partners for the partnership:

Bidder Supplemental Information continued

In the case of a limited partnership (foreign or domestic), is it registered with the Secretary of the State of the State of Texas and authorized to do business in this State?

Yes _____ No _____

In the case of a limited partnership (foreign or domestic), is its general partner(s) registered with the Secretary of State of the State of Texas and authorized to do business in this State?

Yes _____ No _____

If the company is a corporation, please list the exact name of the corporation, whether it is a corporation formed under the laws of the State of Texas or another state, the business address for the corporation, including the state and county, and list the names of all of the officers of the corporation:

In the case of a corporation (foreign or domestic), is it registered with the Secretary of State of the State of Texas and authorized to do business in this State?

Yes _____ No _____

If the company is a limited liability company, please list the exact name of the limited liability company, whether it is a limited liability company formed under the laws of the State of Texas or another state, the business address for the limited liability company, including the state and county, and list the names of all the members/managers for the limited liability company:

In the case of a limited liability company (foreign or domestic), is it registered with the Secretary of State of the State of Texas and authorized to do business in this State?

Yes _____ No _____

In the case of a limited liability company (foreign or domestic), is its member(s)/manager(s) (if not an individual) registered with the Secretary of State of the State of Texas and authorized to do business in this State?

Yes _____ No _____

If the company is another entity not listed above, please lists the exact name and type of company, the state under which it is formed, the business address for the company, including the state and county, and lists the names of all of the persons authorized to act on the company’s behalf:

CITY OF RICHARDSON TERMS AND CONDITIONS OF BIDDING

FOR COOPERATIVE PURCHASING

As permitted under Government Code, Title 7, Chapter 791.025, other governmental entities may wish to cooperatively purchase under the same terms and conditions contained in this contract (piggyback). Each entity wishing to piggyback must have prior authorization from the City and Contractor. If such participation is authorized, all purchase orders will be issued directly from and shipped directly to the entity requiring supplies/services. The City shall not be held responsible for any orders placed, deliveries made, or payment for supplies/services ordered by these entities. Each entity reserves the right to determine their participation in this contract.

IS YOUR FIRM WILLING TO ALLOW OTHER GOVERNMENTAL ENTITIES TO PIGGYBACK OFF

THIS CONTRACT, IF AWARDED, UNDER THE SAME TERMS AND CONDITIONS?

__________YES __________NO

HOW DID YOU HEAR ABOUT US?

The City of Richardson would like to know how you heard about this invitation to bid. Please select from the following options:

__________NEWSPAPER

__________BONFIRE

__________PLAN ROOM

__________CITY REPRESENTATIVE

__________OTHER (PLEASE SPECIFY BELOW)