3-C. RFQ SIGNATURE FORM.pdf

RFQ-BW-26-1003

(MUST BE SUBMITTED WITH THE QUOTE AND FULLY EXECUTED)

"We offer to sell/provide Pasco County, Florida, the above item(s) and/or service(s) at the price(s) stated, in accordance with the terms and conditions attached hereto. In addition, the item(s) and/or service(s) offered above meet all specifications attached hereto, unless otherwise stipulated by exception. This offer to sell/provide is firm for ninety (90) days."

VENDOR MUST BE REGISTERED ON SUNBIZ http://www.sunbiz.org/index.html FLORIDA

DEPARTMENT OF STATE DIVISION OF CORPORATIONS.

(Signature of Vendor —Ink)

(Printed Name and Title)

(Business Name)

Business Name:___________________________________________________________________

(The Name on File with the Internal Revenue Service)

Doing Business as (Fictitious Name):___________________________________________________

Business Address: __________________________________________________________________

Telephone Number:

Email Address: _

If claiming Local Vendor Preference, the Offeror certifies that they satisfy each of the following criteria at the time of their submission of a response to the solicitation necessary to qualify as a “Local Business”: a) a vendor, supplier, or contractor who does business in Pasco County by providing goods, services, or construction; and b) maintains a physical business address located within the jurisdictional limits of Pasco County in an area zoned for the conduct of such business; and c) which the vendor, supplier or contractor operates or performs business on a daily basis; and d) has for at least twelve (12) months prior to the bid or proposal opening date; and (e) a copy of their local business tax receipt or qualifies as a business in a neighboring county as listed in the County’s Purchasing Ordinance. Post office boxes shall not be used for the purpose of establishing said physical address.

http://www.sunbiz.org/index.html

Please put an “X” in the applicable box or mark N/A

Local Business located in Pasco County Business located within Hillsborough, Pinellas, Polk, or Hernando County

This local preference provision is not applicable to those solicitations involving the use of either State or Federal funds as indicated below:

State/Funds Involved: (Y if applicable, N if not applicable)

Note: If claiming Local Vendor Preference, a valid Local Business Tax Receipt must be provided at the time the response is submitted in order to qualify for such consideration.

PASCO COUNTY, FLORIDA

HUMAN TRAFFICKING AFFIDAVIT

This form must be completed by an officer or representative of the company or by the individual entering into, renewing, or extending a contract with Pasco County.

Under penalty of perjury, I hereby attest that based upon my personal knowledge, the below-named company or individual does not use coercion for labor or services, as those terms are defined in section 787.06, Florida Statutes.

Signature

Printed Name

Title

Name of Company if applicable

Date

STATE OF FLORIDA

COUNTY OF_____________________

The foregoing Human Trafficking Affidavit is sworn to (or affirmed) and subscribed before me under penalty of perjury by means of ☐ physical presence or ☐ online notarization, this ______day of________, (month) ________ (year), by _____________________________________________(name of person making statement).

(Signature of Notary Public - State of Florida)

(Print Commissioned Name of Notary Public)

☐ Personally Known OR ☐ Produced Identification

Type of Identification Produced