4-Attachment A - Forms.pdf

RFP2000004266

Attachment A

VENDOR DATA SHEET

The following information is required as part of your response to this solicitation.

Failure to complete and provide this sheet may result in deeming the proposal nonresponsive.

1. Qualifications: 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. eVA Registration Number: __________________________________

3. Vendor’s Primary Contact:

Name: __________________________________ Phone: (_____) _______________________

4. Years in Business: Vendor should have a minimum of 5 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 service: __________ Years ________ Months.

5. Identify any commercial or governmental contracts in the last two years that were not renewed or terminated.

6. References: Provide at least three references for work similar in size and scope to this contract within the past two (2) years, including customer names, contacts and phone number. Each reference must be from different companies/agencies and from different contracts. Use of the same reference may be considered a failure to comply with this provision.

Fairfax County Government (FCG), and Fairfax County Public Schools (FCPS), to include all agencies and authorities, shall be considered as a single entity (one reference) for the purpose of these references.

A. First Reference:

Company: _________________________________Contact: ___________________________ Phone:(_____) ______________________________ Goods/Services Provided: _______________________________________________________ Dates of Service: _______________________________$ Value: ________________________

B. Second Reference:

C. Third Reference:

I certify the accuracy of this information.

By: ____________________________Title: ___________________________Date: ____________

BY SIGNING THIS AFFIRMATION, THE OFFEROR REPRESENTS THAT IT UNDERSTANDS THAT THE FOLLOWING CONTRACT TERMS ARE REQUIRED BY LAW AND CANNOT BE VARIED, REVISED, AMENDED, CHANGED, OR

OTHERWISE NEGOTIATED:

1. Funding: The obligation of the County to pay compensation due the Contractor under the contract or any other payment obligations under any contract awarded pursuant to this contract is subject to appropriations by the Fairfax County Board of Supervisors to satisfy payment of such obligations. The County’s obligations to make payments during subsequent fiscal years are dependent upon the same action. If such an appropriation is not made for any fiscal year, the contract shall terminate effective at the end of the fiscal year for which funds were appropriated and the County will not be obligated to make any payments under the contract beyond the amount appropriated for payment obligations under the contract. The County will provide the Contractor with written notice of non-appropriation of funds within thirty

(30) calendar days after action is completed by the Board of Supervisors. However, the County’s failure to provide such notice will not extend the contract into a fiscal year in which sufficient funds have not been appropriated.

2. Non-discrimination: During the performance of this contract, the Contractor agrees as follows:

a. The Contractor will not discriminate against any employee or applicant for employment because of race, religion, color, sex, national origin, age, disability, or other basis prohibited by state law relating to discrimination in employment, except where there is a bona fide occupational qualification reasonably necessary to the normal operation of the Contractor. The Contractor agrees to post in conspicuous places, available to employees and applicants for employment, notices setting forth the provisions of this non-discrimination clause.

b. The Contractor, in all solicitations or advertisements for employees placed by or on behalf of the Contractor, will state that such Contractor is an equal opportunity employer.

c. Notices, advertisements and solicitations placed in accordance with federal law, rule or regulation shall be deemed sufficient for the purpose of meeting the requirements of this section.

d. The Contractor will include the provisions of the foregoing paragraphs a, b, and c above in every subcontract or purchase order of over $10,000 so that the provisions will be binding upon each subcontractor or vendor.

e. Contractor shall, throughout the term of this contract, comply with the Human Rights Ordinance, Chapter 11 of the Code of the County of Fairfax, Virginia, as reenacted or amended. Contractor shall further require that all of its subcontractors will comply with the Human Rights Ordinance, Chapter 11 of the Code of the County of Fairfax, Virginia, as reenacted or amended.

3. Authorization to Conduct Business in the Commonwealth: A contractor organized as a stock or nonstock corporation, limited liability company, business trust, or limited partnership or registered as a registered limited liability partnership shall be authorized to transact business in the Commonwealth as a domestic or foreign business entity if so required by Title 13.1 or Title 50 of the Code of Virginia or as otherwise required by law. Any business entity described above that enters into a contract with a Fairfax County pursuant to the Fairfax County Purchasing Resolution shall not allow its existence to lapse or its certificate of authority or registration to transact business in the Commonwealth, if so required under Title 13.1 or Title 50, to be revoked or cancelled at any time during the term of the contract. Fairfax County may void any contract with a business entity if the business entity fails to remain in compliance with the provisions of this section.

4. No Indemnification by the County. The parties agree that under applicable law the County cannot indemnify or defend the Contractor. To the extent any promise or term contained in this Contract, including any exhibits, attachments, or other documents incorporated by reference therein, includes an indemnification or obligation to defend by the County, that promise, or term is stricken from this Contract and of no effect.

5. Contractual Disputes:

a. Any dispute concerning a question of fact as a result of a contract with the County which is not disposed of by agreement shall be decided by the Purchasing Agent, who shall reduce her decision to writing and mail or otherwise forward a copy to the Contractor within ninety (90) days. The decision of the Purchasing Agent shall be final and conclusive unless the Contractor appeals within six (6) months of the date of the final written decision by instituting legal action as provided in the Code of Virginia. A Contractor may not institute legal action, prior to receipt of the Purchasing Agent’s decision on the claim, unless the Purchasing Agent fails to render such decision within the time specified.

b. Contractual claims, whether for money or other relief, shall be submitted in writing no later than sixty days after final payment; however, written notice of the Contractor's intention to file such claim shall have been given at the time of the occurrence or beginning of the work upon which the claim is based. Nothing herein shall preclude a contract from requiring submission of an invoice for final payment within a certain time after completion and acceptance of the work or acceptance of the goods. Pendency of claims shall not delay payment of amounts agreed due in the final payment.

AFFIRMATION OF LEGALLY REQUIRED CONTRACT TERMS

6. Drug Free Workplace: During the performance of a contract, the Contractor agrees to (i) provide a drug-free workplace for the Contractor's employees; (ii) post in conspicuous places, available to employees and applicants for employment, a statement notifying employees that the unlawful manufacture, sale, distribution, dispensation, possession, or use of a controlled substance or marijuana is prohibited in the Contractor's workplace and specifying the actions that will be taken against employees for violations of such prohibition; (iii) state in all solicitations or advertisements for employees placed by or on behalf of the Contractor that the Contractor maintains a drug-free workplace; and (iv) include the provisions of the foregoing clauses in every subcontract of over $10,000, so that the provisions will be binding upon each subcontractor or vendor. For the purposes of this section, "drug-free workplace" means a site for the performance of work done in conjunction with a specific contract awarded to a Contractor in accordance with this section, the employees of whom are prohibited from engaging in the unlawful manufacture, sale, distribution, dispensation, possession or use of any controlled substance or marijuana during the performance of the contract.

7. Immigration Reform and Control Act: Contractor agrees that it does not and shall not during the performance of the contract for goods and services in the Commonwealth, knowingly employ an unauthorized alien as defined in the Federal Immigration Reform and Control Act of 1986.

8. Audit of Records: The parties agree that County or its agent must have access to and the right to examine any books, documents, papers, and records of the Contractor involving transactions related to the Contract or compliance with any clauses thereunder, for a period of three (3) years after final payment. The contractor must include this requirement in all subcontracts related to this Contract.

9. Nonvisual Access: All information technology, which is purchased or upgraded by the County under this contract, must comply with the following access standards from the date of purchase or upgrade until the expiration of the Contract:

a. Effective, interactive control and use of the technology (including the operating system), applications programs, and format of the data presented, shall be readily achievable by nonvisual means;

b. The technology equipped for nonvisual access shall be compatible with information technology used by other individuals with whom the blind or visually impaired individual interacts;

c. Nonvisual access technology shall be integrated into networks used to share communications among employees, program participants, and the public; and

d. The technology for nonvisual access shall have the capability of providing equivalent access by nonvisual means to telecommunications or other interconnected network services used by persons who are not blind or visually impaired. A covered entity may stipulate additional specifications in any procurement.

e. Compliance with the nonvisual access standards set out this Section is not required if the Board of Supervisors determines that (i) the information technology is not available with nonvisual access because the essential elements of the information technology are visual and (ii) nonvisual equivalence is not available.

Signature/Date: /

Printed Name/Title: /

Company Name:

FAIRFAX COUNTY’S BUSINESS CLASSIFICATION SCHEDULE

Classify business size or organization type in STEP 1.

STEP 2: Classify ownership (if applicable). Upon completion, return to the requesting staff member. Staff should reference DOF’s vendor setup/modification procedures.

These designations are requested of all vendors including publicly traded corporations, non-profits, employment services organizations, government organizations, partnerships, sole proprietorships, etc. Fairfax County’s definitions mirror the State of Virginia’s (see below and VA’s SBSD for more info). Certification is not required, and Fairfax does not establish preferences or set-asides for specific classifications. Fairfax County’s One Fairfax Policy on racial and social equity commits the County to intentionally consider equity in program and service delivery. Information provided on this form is aggregated and used to report spending patterns.

Send any questions to supplierdiversity@fairfaxcounty.gov.

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.

VENDOR NAME: ____________________________________________ DATE: _____________

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 ☐ Gov’t/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 (ESO) ☐ Small

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

☐ Micro https://www.sbsd.virginia.gov/certification-division/swam/ https://www.fairfaxcounty.gov/topics/one-fairfax mailto:supplierdiversity@fairfaxcounty.gov

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 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.

□ 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: □

Request for Protection of Trade Secrets or Proprietary Information Pursuant to Article 2, Section 5.C.3 of the Purchasing Resolution and VA. Code Ann. § 2.2-4342(F)

The Offeror shall complete this form to protect trade secrets and proprietary information from disclosure under the Virginia Freedom of Information Act. In order to receive protection, you must (a) invoke the protection prior to or upon submission of the data or other materials, (b) identify the data or other materials to be protected, and (c) state the reason(s) why protection is necessary. Each of these requirements must be met with respect to the particular information for which protection is sought.

a) Submission of this form with or without other reference to Article 2, Section 5.C.3 of the Purchasing Resolution or VA. Code Ann. § 2.2-4342(F) shall satisfy the invocation requirement with respect to data or other materials clearly identified herein.

b) Identify the specific data or other material for which protection is sought. Suggested forms of designation include listing the Proposal Section, Tab, or Page numbers; attaching to this form a copy of the table of contents from your Proposal with the relevant trade secret or proprietary contents highlighted; or identifying herein a document stamp used within the Proposal to designate the relevant materials (e.g., “all portions of the Proposal marked “Proprietary” or “Trade Secret””).

The classification of an entire proposal document, line-item prices, and/or total proposal prices as proprietary or trade secrets is not acceptable.

c) For each distinct section of data or other information identified in response to paragraph b), above, state the reason(s) why protection is necessary.

Your explanation must do more than simply stating the materials are “proprietary,” or “trade secrets,” or “not publicly available.” You may attach additional sheets to this form as needed.

Use of this form does not guarantee protection. It is incumbent upon each vendor to meet the prerequisites for protection of their trade secrets or proprietary information. Provision of this form does not constitute legal advice;

you are encouraged to consult with your legal counsel prior to designation of materials for protection.

DATA/MATERIAL TO

BE PROTECTED

SECTION NO.,

& PAGE NO.

REASON WHY PROTECTION IS NECESSARY

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, 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 a copy of your current Fairfax County Business License with your proposal.

Certification Regarding Ethics in Public Contracting

In submitting a proposal, and signing below, Offeror certifies the following in connection with the proposal:

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, 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 the Officials Not to Benefit paragraph in the General Conditions and Instructions to Bidders.

Certification of Financial Solvency for Non-Profit Organizations

In compliance with Fairfax County contracting protocols, the following certification is required by all individuals and organizations awarded a contract:

1. The Board Chair certifies, to the best of his/her knowledge and belief, that the organization is financially solvent, and will remain so during the life of any contract awarded. The Board Chair will notify the county representative in writing of substantial solvency issues such as depletion of cash reserve accounts, use of cash reserves to meet payroll obligations, inability to meet obligations for accounts payable, evidence of deteriorating accounts receivable collection, evidence of delinquency in payment of IRS or payroll taxes, evidence of fraud or mismanagement, co-mingling of accounts, and/or use of grant funds for non-grant purposes.

2. The Executive Director certifies, to the best of his/her knowledge and belief, that the organization is financially solvent, and will remain so during the life of any contract awarded. The Executive Director will notify the county representative in writing within 10 days of substantial solvency issues as outlined in #1 above.

3. 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 contractor rendered an erroneous certification, or if at any time during the course of the contract there are indications that the financial solvency of the contractor affects its ability to complete the terms of the contract, in addition to other remedies available to Fairfax County, the county may terminate the contract for default.

Printed Name of Board Chair: _____________________________________________

Signature/Date: ____________________________________/____________________

Printed Name of Executive Director: ________________________________________

Signature/Date: ____________________________________/____________________

Company Name: ________________________________________________________

Address: _______________________________________________________________

City/State/Zip: __________________________________________________________

SAM.gov Unique Entity Identifier (UEI: __________________________

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IT Services Provider CONSULTANT/CONTRACTOR AGREEMENT CONCERNING ACCESS TO AND USE OF INFORMATION SYSTEMS and COMMUNICATIONS TECHNOLOGY AT FAIRFAX COUNTY, VIRGINIA

I / this firm________________________________________ working as a consultant/contractor/services provider for Fairfax County Government with access to county technology and communications systems, recognize my/our firm’s legal and ethical obligation to conduct work on any Fairfax County information or communications system using computer hardware and devices, and/or software (programming languages, operating systems, databases, third party applications software (COTS) and Web based or ‘cloud’ applications), system utilities, security solutions, monitoring systems, and, data or voice communications software and electronics, Internet capabilities, etc. and county data/content herein referred to as ‘technology’, in a responsible manner and within the guidelines of the County’s IT Security Policy and/or firm’s contract. My/our purpose in using computer-based technology is to perform work for Fairfax County which includes accessing Fairfax County systems through the Internet, and therefore we are subject to the standards, IT Security and Privacy policies, and ethics and behavior policies of Fairfax County Government. As a condition for and in consideration of being given access to computer systems, data, the network, internet, and Fairfax County computer center(s), IT galleries, server rooms, network core facilities, third party hosting centers and ‘clouds’ where county services are provided or supported, I/we affirm that:

I/our firm possess the professional credentials that I or my firm has represented in being hired to perform my/our duty and assignments, and that I/our firm representatives have successfully passed a certifiable criminal background check.

I/our firm will not use Fairfax County technology systems or our firm’s systems to access any information available or acquired from the technology systems for any reason except for purposes directly related to our (firm’s) job assignments and responsibilities as defined by my/my firm’s contract and assignment with the County. I/we will not use Fairfax County technology systems to disclose any information available or acquired from Fairfax County systems for any reason except for purposes directly related to my/my firm’s contract and job assignments and responsibilities for such use as defined by DIT and contract(s). I/we understand that any work I/we perform for Fairfax County that develops systems, logic, or data is the property of Fairfax County, and I/we cannot take or send such products or data without express permission of appropriate Fairfax County authority. I/we will exercise due diligence in providing policy and oversight of our firm’s contractors and sub-contractors. I/we understand that a user agency may ask me/ my firm to sign a separate agreement relating to the privacy and security of the information that a user agency administers, such as for HIPAA, PCI, PII, and/or other Data Privacy Cyber Security laws.

I/ our firm will use vendor provided software and/or utilities only in accordance with that vendor’s license, and such provisions as may have been agreed to between such vendor and Fairfax County. I/we will not deliberately violate any copyright laws or agreements states or implied in my/our use of the software. I/we recognize that to do so makes me/my company liable for any applicable penalties and may lead to my/our firm’s immediate dismissal from the County’s engagement.

I/our firm further understands that the deliberate misuse of Fairfax County technology, data, and/or software which results in the change, damage or destruction of County systems, programs, and/or data is considered destruction of County property and may be considered a breach of contract and/or a criminal offense. I/we understand that our firm may be liable to include immediate release from the engagement for breach of the Fairfax County IT Security Policy, and possible prosecution for the actions of my/this firms actions in the destruction of County property, misuse or theft of classified (sensitive) data. I/we further understand and recognize that there are criminal penalties for deliberate misuse of government information.

I/we have completely read and fully understand the terms of this agreement and accept these terms.

Name of Firm

Firm’s Consultant/Representative Signature Date

Firm Authorized Representative Date

I am acknowledging receipt of this agreement on behalf of Fairfax County, Virginia.

Fairfax County IT Security Officer Date