4-Required Vendor Documentation Form for IFB, RFP and RFQ.pdf

SARA INNAMORATO

COUNTY EXECUTIVE

DEPARTMENT OF ADMINISTRATIVE SERVICES

DIVISION OF PURCHASING AND SUPPLIES

201 COUNTY OFFICE BUILDING ♦ 542 FORBES AVENUE

PITTSBURGH, PA 15219

PHONE (412) 350-4495 ♦ FAX (412) 350-5883

JESSICA GAROFOLO

DIRECTOR

FRANK ALESSIO III, CPPB

CHIEF PURCHASING OFFICER

ATTENTION ALLEGHENY COUNTY SUPPLIERS

ALL OF THE FOLLOWING DOCUMENTS/FORMS MUST

BE COMPLETED, SIGNED WITH LIVE OR ELECTRONIC

SIGNATURES, AND

SUBMITTED WITH YOUR ELECTRONIC BID.

County of Allegheny

ALLEGHENY COUNTY

DEPARTMENT OF ADMINISTRATIVE SERVICES

DIVISION OF PURCHASING AND SUPPLIES

ANTI-SWEATSHOP PROVISIONS

In response to Allegheny County Invitation For Bid or Request For Quotation #_________________, _________________________certifies that nothing has come to my / our attention that would lead I / us to believe that any of the goods or products proposed in our Bid or Quotation were made under sweatshop conditions, as defined by Part 9, § 5-903.02 as amended, of Article 903 of the County’s Administrative Code (Ordinance Number 08-07-OR). I /we certify that I / we have read and understand the above mentioned Administrative Code provisions.

If the County is presented with information that would lead the County to reasonably believe that the Supplier or its suppliers may be obtaining goods or products for sale, re-sale, lease or rental to the County that where made under sweatshop condition, upon request of the County, the Supplier shall disclose information, data and materials reflecting

Supplier’s practices as they pertain to the procurement and manufacturing of goods/products in compliance with the Anti-

Sweatshop provisions of the County’s Administrative Code.

COMPANY NAME: ___________________________________________________________

ADDRESS: ___________________________________________________________________

PHONE NO: ______________________ FAX NO: ___________________________

CONTACT PERSON:_____________________________ E-MAIL: ________________________

AUTHORIZED SIGNATURE ______________________________________________________

TITLE OF AUTHORIZED SIGNER __________________________________________________

NOTE: This document MUST be completed and submitted with your electronic Bid or Quotation.

Jd/ anti sweatshop supdoc

Do you agree to make available to the Councils of Government, Municipalities, Authorities and School Districts within Allegheny County, all items contained in this bid at the bid price quoted for the entire Contract Period?

(Please be advised as this is a co-operative Invitation for Bid, this optional contract availability is not applicable to the

City of Pittsburgh as your act of submitting a bid enables both the County and City to utilize the resultant contract.

YES NO

Do you agree to make available to all political sub-division and authorities of the Commonwealth of Pennsylvania all items contained in this bid at the bid price quoted for the entire Contract Period?

(Please be advised as this is a co-operative Invitation for Bid, this optional contract availability is not applicable to the

City of Pittsburgh as your act of submitting a bid enables both the County and City to utilize the resultant contract.

YES NO

BUY AMERICAN CERTIFICATE

The bidder or offeror hereby certifies that each end product, except the end products listed below, is a domestic source end product (as defined in the clause entitled "Buy American Policy"); and that components of unknown origin have been considered to have been mined, produced, or manufactured outside the United States.

List the sum of the declared values of all the imported components installed or included on such products.

COMPANY INFORMATION

(This information is for tracking purposes only and has no role in the determination of the lowest, responsive, responsible bidder.)

[ ] check here if your firm is registered with the Allegheny County Department of Minority, Women and Disadvantaged

Business Enterprises

[ ] check here if your firm is a “Minority Business Enterprise” or “MBE” as defined in the Small Business Act, 15 USC

[ ] check here if your firm is a “Women Business Enterprise” or “WBE” as defined in the Small Business Act, 15 USC

[ ] check here if your firm is a “Small Business” as defined by the Small Business Administration (13 C.F.R. 121.201, in most cases, this means a business with 500 or fewer employees)

__________________________________ *** FOR PAYMENT PURPOSES ***

Print Name of Business

Business Address Remit to Address

City State Zip Code City State Zip Code

Contact Person Telephone Contact Person Telephone

(Print Name) Number (Print Name) Number

800 number if one is applicable Email

FAX number if one is applicable

Email

IN THE PRESENCE OF -

INDIVIDUAL

Witness (Individual Principal)

PARTNERSHIP

Witness (Partner)

Witness (Partner)

Witness (Partner)

CORPORATION

attest Secretary President

(State where Incorporated)

NOTE: THIS PAGE MUST BE SUBMITTED WITH YOUR BID, WITH A LIVE OR

ELECTRONIC SIGNATURE SIGNED IN BLUE INK.