3-Appendix B - All Forms.pdf

Office of Procurement Services 8115 Gatehouse Road, Suite 4400 Falls Church, VA 22042

CONTACT INFORMATION

1. Contract Administration

Designated central point of contact for questions related to the solicitation and post award matters.

NAME: TITLE: __________________________

ADDRESS: __________________________________ PHONE: (___) ____________________

EMAIL:

2 Contract ordering

In the event your firm receives a contract as a result of this Invitation for Bid, please provide the designated central point of contact we may reach during the period of the contract term.

NAME: _____________________________________ TITLE: __________________________

ADDRESS: __________________________________ PHONE: (___) ____________________

EMAIL: _______________________________________________________________________

3. Accounting Administration

In the event your firm receives a contract as a result of this Invitation for Bid, please provide the designated central point of contact we may reach during the period of the contract term for questions related to accounting matters.

NAME: ____________________________________ TITLE: __________________________

ADDRESS: _________________________________ PHONE: (___) ___________________

EMAIL: ______________________________________________________________________

Falls Church, VA 22042

BIDDER DATA SHEET

NAME OF BIDDER:

ADDRESS:

E-MAIL ADDRESS:

*Name and e-mail addresses of both service and fiscal representatives (Key Personnel) who would handle this account.

Service representative:

Telephone number: ( ) Email address:

Fiscal representative:

Telephone number: ( ) Email address:

Payment address, if different from above:

Falls Church, VA 22042

VIRGINIA STATE CORPORATION COMMISSION (SCC)

REGISTRATION INFORMATION

The bidder:

□ 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 bidder 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 bidder’s out-of-state location) -OR-

□ is an out-of-state business entity that is including with this bid/proposal an opinion of legal counsel which accurately and completely discloses the undersigned bidder’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 bids:

Signature Date

Falls Church, VA 22042

BUSINESS, PROFESSIONAL AND OCCUPATIONAL LICENSE

All firms located or operating in Fairfax County must obtain a Business, Professional and Occupational License (BPOL) as required by Chapter 4, Article 7, of the Code of the County of Fairfax, Virginia. In order for the Department of Tax Administration to determine your BPOL requirement prior to contract award, it is necessary for you to provide the following information:

• If you currently have a Fairfax County business license, please submit a copy with your proposal.

• Do you have an office in: Virginia Yes No Fairfax County Yes No

• Date business began/will begin work in Fairfax County:

A detailed description of the business activity that will take place in Fairfax County. If business is located outside of Fairfax County, give the percentage of work actually to be done in the County.

Signature Date

Complete and return this form or submit a copy of your current Fairfax County Business License with your bid.

Falls Church, VA 22042

CERTIFICATION REGARDING DEBARMENT OR SUSPENSION

In compliance with contracts and grants agreements applicable under the U.S. Federal Awards Program, the following certification is required by all bidders submitting a bid in response to this Invitation for Bid:

1. The Bidder certifies, to the best of its knowledge and belief, that neither the Bidder nor its Principals are suspended, debarred, proposed for debarment, or declared ineligible for the award of contracts from the United States federal government procurement or non-procurement programs, or are listed in the List of Parties Excluded from Federal Procurement and Non-procurement Programs issued by the General Services Administration.

2. “Principals,” for the purposes of this certification, means officers, directors, owners, partners, and persons having primary management or supervisory responsibilities within a business entity (e.g., general manager, plant manager, head of a subsidiary, division, or business segment, and similar positions).

3. The Bidder shall provide immediate written notice to the Fairfax County Purchasing Agent if, at any time prior to award, the Bidder learns that this certification was erroneous when submitted or has become erroneous by reason of changed circumstances.

4. This certification is a material representation of fact upon which reliance will be placed when making the award. If it is later determined that the Bidder rendered an erroneous certification, in addition to other remedies available to Fairfax County government, the Fairfax County Purchasing Agent may terminate the contract resulting from this solicitation for default.

Printed Name of Representative:

Signature: Date:

Company Name:

Address:

City: State: Zip:

SSN or TIN No:

Falls Church, VA 22042

Certification Regarding Ethics in Public Contracting

In submitting this bid and signing below, Bidder certifies the following in connection with a bid:

Check one:

1. I have not given any payment, loan, subscription, advance, monetary deposit, services or anything of more than nominal value to any public employee or official who has official responsibility and authority for procurement transactions.

2. I have given a payment, loan, subscription, advance, monetary deposit, services or anything of more than nominal value to a public employee or official who has official responsibility and authority for procurement transactions, and in exchange I received consideration of substantially equal or greater value.

3. I have given a payment, loan, subscription, advance, monetary deposit, services or anything of more than nominal value to a public employee or official who has official responsibility and authority for procurement transactions, but in exchange I have not received consideration of substantially equal or greater value.

If #2 above 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:

Date:

Printed Name of Bidder Representative:

Signature:

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.

Falls Church, VA 22042

Sample Listing of Local Public Bodies

REFERENCE, SPECIAL PROVISIONS, PARAGRAPH TITLED “USE OF CONTRACTS BY OTHER PUBLIC BODIES.” You may select those public bodies that this contract may be extended to; a “blank” will signify a “NO” response:

Alexandria Public Schools, VA Manassas Park, Virginia Alexandria Sanitation Authority Maryland-National Capital Park & Planning

Commission Alexandria, Virginia Maryland Transit Administration Arlington County, Virginia Metropolitan Washington Airports Authority Arlington Public Schools, Virginia Metropolitan Washington Council of

Governments Bladensburg, Maryland Montgomery College Bowie, Maryland Montgomery County, Maryland Charles County Public Schools, MD Montgomery County Public Schools College Park, Maryland Northern Virginia Community College Culpeper County, Virginia Omni Ride District of Columbia Potomac & Rappahannock Trans.

Commission District of Columbia Courts Prince George's County, Maryland District of Columbia Public Schools Prince George's County Public Schools DC Water and Sewer Authority Prince William County, Virginia Fairfax County Water Authority Prince William County Public Schools, VA Fairfax, Virginia (City) Prince William County Service Authority Falls Church, Virginia Rockville, Maryland Fauquier County Government and Schools, Virginia

Spotsylvania County Schools, Virginia

Frederick, Maryland Stafford County, Virginia Frederick County Maryland Takoma Park, Maryland Gaithersburg, Maryland Upper Occoquan Sewage Authority Greenbelt, Maryland Vienna, Virginia Herndon, Virginia Virginia Railway Express Leesburg, Virginia Washington Metropolitan Area Transit

Authority Loudoun County, Virginia Washington Suburban Sanitary Commission Loudoun County Public Schools Winchester, Virginia Loudoun County Sanitation Authority Winchester Public Schools Manassas, Virginia Manassas City Public Schools, Virginia

Complete and return this form with your proposal.

Vendor Name

BUSINESS CLASSIFICATION

DEFINITIONS

Small Business – means a business, independently owned or operated 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 the individual owners shall control both the management and daily business operations of the small business.

Minority-Owned Business – means a business concern that is at least 51% owned by one or more minority individuals who are U.S. citizens or legal resident aliens, 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 liability company or other entity is owned by one or more minority individuals who are U.S. citizens or legal resident aliens, and both the management and daily business operations are controlled by one or more minority individuals.

Woman-Owned Business – means 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 liability 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.

YOU MUST CLASSIFY YOUR BUSINESS/ORGANIZATION BY MARKING THE APPROPRIATE BOXES

ON THE COVER SHEET (DPSM32). This designation is required of all business/organizations including publicly traded corporations, non-profits, sheltered workshops, government organizations, partnerships, sole proprietorships, etc.

BUSINESS CLASSIFICATION

DEFINITIONS

Small Business – means a business, independently owned or operated 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 the individual owners shall control both the management and daily business operations of the small business.

Minority-Owned Business – means a business concern that is at least 51% owned by one or more minority individuals who are U.S. citizens or legal resident aliens, 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 liability company or other entity is owned by one or more minority individuals who are U.S. citizens or legal resident aliens, and both the management and daily business operations are controlled by one or more minority individuals.

Woman-Owned Business – means 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 liability 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.

YOU MUST CLASSIFY YOUR BUSINESS/ORGANIZATION BY MARKING THE APPROPRIATE BOXES

ON THE COVER SHEET (DPSM32). This designation is required of all business/organizations including publicly traded corporations, non-profits, sheltered workshops, government organizations, partnerships, sole proprietorships, etc.

Falls Church, VA 22042

SUBCONTRACTOR (S) NOTIFICATION FORM

Solicitation No. / Title: ____________________________________________

Prime Contractor's Name: _________________________________________

Prime Contractor’s Classification: ________________

You are required to provide the County with names, addresses, anticipated dollar amount and small/minority classification of each first-tier subcontractor (ref. Special Provisions, titled “Subcontracting”). Please complete this form and return it with your submission.

Please check here if you are not using a subcontractor: _____

SUBCONTRACTOR(S)

NAME

STREET ADDRESS CITY STATE ZIP CODE ANTICIPATED DOLLAR

AMOUNT

VENDOR

CLASSIFICATION

Complete and return this form with your bid.