5-Attachment A1-A4.pdf

IFB 2000004310

Attachment A1

SAFETY VIOLATIONS CERTIFICATE:

List safety violations, Ref: Special Provisions Paragraph 6.

If there were no safety violations, execute the following certification:

I hereby certify that: has not received any

(Name of Bidding Firm) citations for safety violations described in Special Provisions paragraph 6, which have become final within three years prior to bid submission.

Principal

State of:

County of:

On this day of , 20 , after first being duly sworn, appeared before me, the undersigned Notary Public, and executed the foregoing instrument and acknowledged to me that he executed the same as and for the act and deed of said firm.

Notary Public

Seal

My commission expires: , 20 .

Attachment A2

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.

□ check the 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.

Attachment A3

PLEASE CLASSIFY YOUR BUSINESS/ORGANIZATION BY MARKING IN STEP 1. STEP 2 IS OPTIONAL. This designation is requested of all business/organizations including publicly traded corporations, non-profits, sheltered workshops, government organizations, partnerships, sole proprietorships, etc. Fairfax County does not certify business classifications nor does it establish preferences or set-asides for specific classifications.

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 Agency/Public Body” in Step 1

NAME OF BUSINESS: ____________________________________________________________________________

LAST 4 DIGITS OF TIN/EIN: ______________ SIGNATURE: _____________________________________________

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: Please indicate the classification of your business/organization. Select ONLY one (1) option.

☐ Large ☐ Non-Profit ☐ Government/Public Body

Step 2 (OPTIONAL): Please indicate what type of ownership your business/organization consists of. You may choose MORE than one (1) option.

☐ Employment Services Organization ☐ Small

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

☐ Micro

Attachment A4

Certification Regarding Ethics in Public Contracting

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

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, 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:

Printed Name of Bidder Representative: ___________________________________

Signature/Date: ____________________________________ / _______________

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.