3-20000004270 - Attachment A - Forms.pdf

IFB 2000004270

Attachment A1

VENDOR DATA SHEET

Vendor Note: The following information is required as part of your response to this solicitation. Failure to complete and provide this sheet may result in finding your bid nonresponsive.

1. Qualification: The vendor must have the capability and capacity in all respects to satisfy fully all the contractual requirements and be a regular dealer, supplier and/or an authorized dealer of the goods or services offered.

2. Vendor’s Primary Contact:

Name: __________________________________ Phone: _________________________

3. Years in Business: Vendor must have a minimum of 3 years’ experience providing the type of goods and/or services requested in this solicitation. Indicate the length of time you have been in business providing this type of good or service:

__________ Years ________ Months

4. Vendor Information: eVA Vendor ID: ________________________________

5. References: Indicate below a listing of at least three (3) current or recent accounts, either commercial or governmental, that your company is servicing, has serviced, or has provided similar goods. Include the length of service and the name, address, and telephone number of the point of contact.

A. Company:________________________________ Contact: _____________________________

Phone:(_____)____________________________ Email:________________________________

Goods/Services Provided: ________________________________________________________

Dates of Service: _________________________________$ Value: _______________________

B. Company_____________________________ Contact: ________________________________

Phone:(_____)_________________________ Email:________________________________

Goods/Services Provided:________________________________________________________

Dates of Service: ______________________________$ Value: ________________________

C. Company:____________________________ Contact: ________________________________

Phone:(_____)_________________________ Email:________________________________

Goods/Services Provided:________________________________________________________

Dates of Service: ______________________________$ Value: ________________________

I certify the accuracy of this information.

Signed: ________________________________Title: _____________________________ Date: _______________

Attachment A2

FAIRFAX COUNTY’S BUSINESS CLASSIFICATION SCHEDULE

CLASSIFY YOUR BUSINESS/ORGANIZATION BY MARKING IN STEP 1.

STEP 2 IS OPTIONAL. This designation is requested of all businesses/organizations including publicly traded corporations, non-profits, employment services organizations, government organizations, partnerships, sole proprietorships, etc. Fairfax County does not certify business classifications nor does it establish preferences or set-asides for specific classifications.

Examples:

• A small, Asian women-owned business would mark “Small” in Step 1, then “Women-Owned” and “Minority- Owned” in Step 2

• A small, service-disabled veteran and women-owned business would mark “Small” in Step 1, then “Women- Owned” and “Service-Disabled Veteran-Owned” in Step 2

• A government agency/public body would ONLY mark “Government/Public Body” in Step 1

NAME OF BUSINESS: ________________________________________LAST 4 DIGITS OF TIN/EIN: _______

DEFINITIONS

Micro Business/Organization: “Micro business” means a business that has no more than twenty-five (25) employees AND no more than $3 million in average annual revenue over the prior three-year period.

Small Business/Organization: “Small business” means a business that is at least 51% independently owned and controlled by one or more individuals who are U.S. citizens or legal resident aliens, and together with affiliates, has 250 or fewer employees, or average annual gross receipts of $10 million or less averaged over the previous three years. One or more of these individual owners shall control both the management and daily business operations of the small business.

Minority-Owned Business: is a business that is at least 51% owned by one or more minority individuals or in the case of a corporation, partnership or limited liability company, or other entity, at least 51% of the equity ownership interest in the corporation, partnership or limited company or other entity is owned by one or more minority individuals and both the management and daily business operations are controlled by one or more minority individuals. Such individuals shall include Asian American, African American, Hispanic American, Native American, Eskimo, or Aleut.

Women-Owned Business: a business that is at least 51% owned by one or more women who are U.S. citizens or legal resident aliens, or in the case of a corporation, partnership or limited company or other entity, at least 51% of the equity ownership interest is owned by one or more women who are U.S. citizens or legal resident aliens, and both the management and daily business operations are controlled by one or more women who are U.S. citizens or legal resident aliens.

Service-Disabled Veteran: means a veteran who (i) served on active duty in the United States military ground, naval, or air service, (ii) was discharged or released under conditions other than dishonorable, and (iii) has a service - connected disability rating fixed by the United States Department of Veterans Affairs.

Service-Disabled Veteran-Owned Business: is a business that is at least 51 percent owned by one or more service -disabled veterans or, in the case of a corporation, partnership, or limited liability company or other entity, at least 51 percent of the equity ownership interest in the corporation, partnership, or limited liability company or other entity is owned by one or more individuals who are service-disabled veterans and both the management and daily business operations are controlled by one or more individuals who are service-disabled veterans.

Employment Services Organization: a private non-profit, state, or local government institution that provides employment opportunities for individuals who are developmentally, physically, or mentally impaired, to prepare for gainful work in the general economy. These services may include physical rehabilitation, training in basic work and life skills (e.g., how to apply for a job, attendance, personal grooming, and handling money), training on specific job skills, and providing work experience.

Step 1: Indicate the classification of your business/organization. Select ONLY one (1) option.

☐ Large ☐ Non-Profit ☐ Government/Public Body

Step 2 (OPTIONAL): Indicate what type of ownership your business/organization consists of. You may choose MORE than one (1) option.

☐ Employment Services Organization ☐ Small

☐ Women-Owned ☐ Minority-Owned ☐ Service-Disabled Veteran-Owned

☐ Micro

Attachment A3

VIRGINIA STATE CORPORATION COMMISSION (SCC)

REGISTRATION INFORMATION

The offeror:

□ is a corporation or other business entity with the following SCC identification number:

________________________________ -OR-

□ is not a corporation, limited liability company, limited partnership, registered limited liability partnership, or business trust -OR-

□ is an out-of-state business entity that does not regularly and continuously maintain as part of its ordinary and customary business any employees, agents, offices, facilities, or inventories in Virginia (not counting any employees or agents in Virginia who merely solicit orders that require acceptance outside Virginia before they become contracts, and not counting any incidental presence of the offeror in Virginia that is needed in order to assemble, maintain, and repair goods in accordance with the contracts by which such goods were sold and shipped into Virginia from offeror’s out-of-state location) -OR-

□ is an out-of-state business entity that is including with this proposal an opinion of legal counsel which accurately and completely discloses the undersigned offeror’s current contacts with Virginia and describes why whose contacts do not constitute the transaction of business in Virginia within the meaning of § 13.1-757 or other similar provisions in Titles

13.1 or 50 of the Code of Virginia.

□ Please check the following box if you have not checked any of the foregoing options but currently have pending before the SCC an application for authority to transact business in the Commonwealth of Virginia and wish to be considered for a waiver to allow you to submit the SCC identification number after the due date for proposals.

Attachment A4

Certification Regarding Ethics in Public Contracting

In submitting this proposal, and signing below, Bidder/Offeror certifies the following in connection with a bid, proposal, or contract:

Check one:

1. I have not given any payment, loan, subscription, advance, deposit of money, services or anything of more than nominal or minimal value to any public employee or official have official responsibility for a procurement transaction.

2. I have given a payment, loan, subscription, advance, deposit of money, services or anything of more than nominal or minimal value to a public employee or official have official responsibility for a procurement transaction, but I received consideration in substantially equal or greater value in exchange.

If 2 is selected, please complete the following:

Recipient: _____________________________________________________

Date of Gift: _____________________________________________________

Description of the gift and its value:

Description of the consideration received in exchange and its value:

Printed Name of Offeror Representative: _______________________________

Signature/Date: ____________________________________ / _______________

Company Name: _____________________________________________________

Company Address: _____________________________________________________

City/State/Zip: _____________________________________________________

This certification supplements but does not replace the requirements set forth in paragraph 59 (OFFICIALS NOT TO BENEFIT) of the General Conditions and Instructions to Bidders included in this solicitation.

Attachment A5

Please provide the following information on your company letter head:

Vendor name:

Doing Business As/(Trade Name):

Corporate Address (Address Listed on W9):

Zip code: (please include last four digits)

Remittance Address ☐ :

Contact name:

Email:

Phone: FAX:

Standard Method of Communication: EMAIL ☐ FAX ☐ MAIL ☐ OTHER ☐

Purchase Order Address ☐

Contact name:

Email:

Phone: FAX:

Standard Method of Communication: EMAIL ☐ FAX ☐ MAIL ☐ OTHER ☐