3-Certifications.pdf

CDL Program

Contractor’s Statement of Compliance

Due to the nature of the work which this contractor may perform for this employer, this contractor must use employees who perform safety-sensitive functions for which a Commercial Driver’s

License (CDL) is typically required. Under federal Department of Transportation regulations (49

CFR Parts 40 and 382), the contractor is responsible for implementing a drug and alcohol testing program for these employees. Prior to being awarded any contract by the Local Government and every six months thereafter of the contract, this contractor must certify its compliance with these regulations to the Local Government by signing the form below.

This hereby certifies that on , (Date) (Name of Contractor) did provide the Local Government with the following information attesting to the contractor’s current participation in a qualified drug and alcohol testing program.

Testing Program Name

Program Contact Person

Address State ZIP Code

Phone Number

Contractor Signature

(Name and Title)

CERTIFICATION OF BIDDER REGARDING EQUAL EMPLOYMENT OPPORTUNITY

INSTRUCTIONS

This certification is required pursuant to Executive Order 11246 (30 F.R. 12319-25). The implementing rules and regulations provide that any bidder or prospective contractor, or any of their proposed subcontractors, shall state as an initial part of the bid or negotiations of the contract whether it has participated in any previous contract or subcontract subject to the Equal Employment Opportunity

Clause; and, if so, whether it has filed all compliance reports due under applicable instructions.

Where the certification indicates that the Bidder has not filed a compliance report due under applicable instructions, such Bidder shall be required to submit a compliance report within seven (7) calendar days after bid opening. No contract shall be awarded unless such report is submitted.

CERTIFICATION BY BIDDER

NAME AND ADDRESS OF BIDDER (Include ZIP code)

1. Bidder has participated in a previous contract or subcontract subject to the Equal Employment

Opportunity Clause.

Yes No

2. Compliance reports were required to be filed in connection with such contract or subcontract.

3. Bidder has filed all compliance reports due under applicable instructions, including SF-100.

Yes No None required

4. Have you ever been or are you being considered for sanction due to violation of Executive Order

11246, as amended?

Name and Title of Signer (Please Type)

Signature Date

CERTIFICATION OF NON-SEGREGATED FACILITIES AND NON-

EMPLOYMENT OF ILLEGAL ALIEN LABOR

The Bidder certifies that he/she does not maintain or provide for his/her employees any segregated facilities at any of his/her establishments, and that he/she does not permit his/her employees to perform their services at any location, under his/her control, where segregated facilities are maintained. The Bidder agrees that a breach of this certification will be a violation of the Equal Employment Opportunity Clause in any contract resulting from acceptance of this Bid. As used in this certification, the term “segregated facilities" means any waiting rooms, work areas, restrooms and washrooms, restaurants and other eating areas, time clocks, locker rooms and other storage or dressing areas, parking lots, drinking fountains, recreation or entertainment areas, transportation, and housing facilities provided for employees which are segregated by explicit directive or are in fact segregated on the basis of race, color, religion, or national origin, because of habit, local custom, or otherwise. The Bidder agrees that (except where he/she has obtained identical certifications from proposed subcontractors) prior to the award of subcontracts exceeding $10,000 which are not exempt from the provisions of the Equal Employment Opportunity Clause, that he/she will retain such certifications in his/her files.

The Bidder further certifies in accordance with Act 43 (PL May 11, 2006) that he/she shall not knowingly employ, or knowingly permit any of its subcontractors to knowingly employ, the labor services of an illegal alien.

In the event that the Bidder

(a) knowingly employs or knowingly permits any of its subcontractors to knowingly employ, the labor services of an illegal alien; and

(b) the Bidder or any of its subcontractors are sentenced under Federal law for an offense involving knowing use of labor by an illegal alien, The Bidder shall be subject to penalty as prescribed in Pennsylvania Act 43 (PL May 11, 2006).

NOTE: The penalty for making false statements in offers is prescribed in 18 U.S.C. § 1001.

Date: , 20

(Name of Bidder)

Official Address By:

(including ZIP CODE):

(Title)

Employer Identification Number

NON-COLLUSION AFFIDAVIT OF PRIME BIDDER

State of ) County of )

, being first duly sworn, deposes and says that:

1) He/She is (OWNER, Partner, Officer, Representative or Agent) of

, the bidder that has submitted the attached Bid;

2) He/She is fully informed respecting the preparation and contents of the attached Bid and of all pertinent circumstances respecting such Bid;

3) Such Bid is genuine and is not a collusive or sham Bid;

4) Neither the said bidder nor any of its officers, partners, owners, agents, representatives, employees or parties in interest, including this affiant, has in any way colluded, conspired, connived, or agreed, directly or indirectly, with any other bidder firm or person to submit a collusive or sham Bid in connection with the Contract for which the attached Bid has been submitted, or to refrain from bidding in connection with such Contract, or has in any manner, directly or indirectly, sought by agreement or collusion or communication or conference with any other bidder, firm or person to fix the price or prices in the attached Bid or of any other bidder, or to fix any overhead, profit, or cost element for the Bid prices or the Bid price of any other bidder, or to secure through any collusion, conspiracy, connivance or unlawful agreement any advantage against the or any person interested in the proposed Contract; and

5) The price or prices quoted in the attached Bid are fair and proper and are not tainted by any collusion, conspiracy, connivance or unlawful agreement on the part of the bidder or any of its officers, partners, agents, representatives, owners, employees, or parties in interest, including this affiant.

Signed

Title

Subscribed and sworn to before me this day of , Signature

Title (Seal) My

Commission Expires

COMMONWEALTH OF PENNSYLVANIA

PUBLIC WORKS EMPLOYMENT VERIFICATION

FORM

Date

Business or Organization Name (Employer)

Address

City State Zip Code

Contractor Subcontractor (check one)

Contracting Public Body

Contract/Project No

Project Description

Project Location

As a contractor/subcontractor for the above referenced public works contract, I hereby affirm that as of the above date, our company is in compliance with the Public Works Employment Verification

Act (‘the Act’) through utilization of the federal E-Verify Program (EVP) operated by the United

States Department of Homeland Security. To the best of my/our knowledge, all employees hired post January 1, 2013 are authorized to work in the United States.

It is also agreed to that all public works contractors/subcontractors will utilize the federal EVP to verify the employment eligibility of each new hire within five (5) business days of the employee start date throughout the duration of the public works contract. Documentation confirming the use of the federal EVP upon each new hire shall be maintained in the event of an investigation or audit.

I, , authorized representative of the company above, attest that the information contained in this verification form is true and correct and understand that the submission of false or misleading information in connection with the above verification shall be subject to sanctions provided by law.

Authorized Representative Signature

SAFETY GUIDELINES AND REQUIREMENTS

1. The CONTRACTOR will be responsible for initiating, maintaining and supervising all safety precautions and programs in connection with the WORK. He will take all necessary precautions for the safety of, and will provide the necessary protection to prevent damage, injury or loss to all employees on the WORK and other persons who may be affected thereby, all the WORK and all materials or equipment to be incorporated therein, whether in storage on or off the site, and other property at the site or adjacent thereto, including trees, shrubs, lawns, walks, pavements, roadways, structures and utilities not designated for removal, relocation or replacement in the course of construction.

2. The CONTRACTOR will erect and maintain, as required by the conditions and progress of the

WORK, all necessary safeguards for safety and protection. He will notify owners of adjacent utilities when prosecution of the WORK may affect them. The CONTRACTOR will remedy all damage, injury or loss to any property, caused directly or indirectly, in whole or in part, by the

CONTRACTOR, any SUBCONTRACTOR or anyone directly or indirectly employed by any of them or anyone for whose acts any of them be liable, except damage or loss attributable to the fault of the CONTRACT DOCUMENTS or to the acts or omissions of the OWNER or anyone employed by either of them or anyone for whose acts either of them may be liable and not attributable, directly or indirectly, in whole or in part, to the fault or negligence of the CONTRACTOR.

3. In emergencies affecting the safety of persons or the WORK or property at the site or adjacent thereto, the CONTRACTOR, without special instruction or authorization from the OWNER shall act to prevent threatened damage, injury or loss. He will give the OWNER prompt WRITTEN

NOTICE of any significant changes in the WORK or deviations from the CONTRACT

DOCUMENTS caused thereby, and a CHANGE ORDER shall thereupon be issued covering the changes and deviations involved.

4. The Contractor will keep himself fully informed of, and shall carefully observe and comply with all

State, County and local laws, ordinances and regulations which in any manner affect the conduct of the Work, and all such orders or decrees as exist at present and those which may be enacted later, of bodies having any jurisdiction or authority over the work, and shall indemnify and save harmless the

OWNER and all its officers, agents and servants against any claim or liability arising from or based upon the violation of any such law, ordinance, regulation, order or decree, whether by himself or his employees.

5. All safety procedures outlined by the Occupational Safety and Health Administration (OSHA), will be strictly adhered to; all safety training required in the above-mentioned regulations has been provided and successfully completed by all employees; and all safety equipment, mandated by those regulations, will be provided and utilized in the completion of this project. False statements and non-compliance to these safety procedures will result in immediate termination of this contract.

Understanding of the above safety guidelines and requirements is hereby acknowledged this day of , 20 . Name and Address of Bidder:

SEAL

Zip Code:

Signature Name and Title of Signer (Please Type)

STATEMENT OF BIDDER'S QUALIFICATIONS

All questions/items below must be answered, and the date given must be clear and comprehensive. This statement must be notarized. If necessary, questions may be answered on separate, attached sheets.

The bidder may submit any additional information he/she desires.

1. Name of bidder:

2. Permanent main office address:

3. When organized:

4. If a corporation, where incorporated:

5. How many years have you been engaged in the contracting business under your present firm or trade name?

6. Contracts on hand: (Schedule these, showing amount of each contract and the appropriate anticipated dates of completion.)

7. General character of work performed by your company:

8. Have you ever failed to complete any work awarded to you? If so, where and why?

9. Have you ever defaulted on a contract? If so, where and why?

10. List the more important projects recently completed by your company, stating the approximate cost for each, and the month and year completed:

11. List your major equipment available for this contract:

12. Experience in construction work similar in importance to this Project:

13. Background and experience of the principal members of your organization, including the officers:

14. Credit Available: $

15. Give bank reference:

16. Will you, upon request, fill out a detailed financial statement and furnish any other information that may be required by the (OWNER)?

17. The undersigned certifies for itself, it has no unsatisfied tax liabilities or other Commonwealth obligations.

18. The undersigned certifies for itself and all of its subcontractors and suppliers that it is not under suspension or debarment by the Commonwealth or any governmental entity, instrumentality, or authority.

19. The undersigned hereby authorizes and requests any person, firm, or corporation to furnish any information requested by the (OWNER) in verification of the recitals comprising this Statement of Bidder's Qualifications.

Dated at this day of , 20 .

(Name of Bidder)

By:

Title:

State of )

County of )

, being a duly sworn representative of deposes and says that all statements herein contained are true and correct.

Subscribed and sworn to before me this day of , 20 .

Notary Public

My commission expires , 20 .

STATEMENT OF BIDDER'S QUALIFICATIONS (continued)

Certifications:

I, , certify that

I am the of the Corporation named as

CONTRACTOR herein; that who signed this Agreement on behalf of the CONTRACTOR, was the of said Corporation;

that said Agreement was duly signed for and in behalf of said Corporation by authority of its governing body, and is within the scope of its corporate powers.

Title:

(Corporate Seal)

AFFIDAVIT RE

ACCEPTING PROVISIONS OF THE WORKMEN’S

COMPENSATION ACT

State of )

) ss:

County of )

Being duly sworn according to law deposes and says that they have accepted the provisions of the Workmen’s

Compensation Act of

1915 of the Commonwealth of Pennsylvania, with its supplements and amendments, and has insured their liability thereunder in accordance with the terms of said Act with .

(COMPANY)

(TYPE OR PRINT) CONTRACTOR

BY: