5-FORM A – COMPANY INFORMATION.pdf

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FORM A – COMPANY INFORMATION

Notice This form requires an original manual signature after each subsection, a manual signature on the final page and must be included with the proposal.

STATE OF §

§ AFFIDAVIT OF OWNERSHIP, CONTROL

COUNTY OF § AND CORPORATE INFORMATION

I, _________________________________________________ [full name] (hereafter “affiant”), ______________________________________________________ [state title/capacity with proposal] of

______________________________________________________ (proposal’s corporate/legal name), who

ASSURE THE DISTRICT OF THE FOLLOWING:

1. Affiant is authorized to give this affidavit and has personal knowledge of the facts and matters herein stated;

2. Proposer(s) seeks to do business with the District in connection with [RFP NUMBER AND TITLE] which is expected to be in an amount that exceeds $10,000.

□ yes

3. The following information is submitted in connection with the proposal, submission or bid of Proposer in connection with the above described project or matter.

Company name: Company’s EIN #

Home office: Local office:

Address:

City:

State: Zip:

Telephone: Fax:

Contact Person’s Name:

Contact Person’s Telephone Number: Fax number:

Contact Person’s E-mail Address:

4. Number of years your organization has been in continuous operation:

5. Number of years your organization has been in business under its present business name:

6. Does your company pay taxes to the Manor independent school district?

7. IF YES, are your tax payments to MISD current?

8. Does any officer, partner, owner, sales representative and/or spouse work for the Manor Independent School District?

□ no

9. Type of business entity:

□ publicly traded corporation

□ private corporation

□ limited partnership

□ partnership

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□ sole proprietorship

□ not for profit entity yes no

10. If corporation, answer the following questions:

Date of Incorporation:

State of Incorporation:

Charter Number:

President:

Vice President:

Corporate Secretary:

Treasurer:

11. If partnership or corporation, date of organization creation:

12. If sole proprietor, number of years in business:

13. Number of years doing business with MISD:

14. Do you have experience with other school districts?

15. If yes, please list names of school districts:

16. Name and complete address of all partners listed on a separate sheet and attached.

17. If other than corporation or partnership, describe organization and name of principals:

18. Check one of the following:

□ proposer will provide goods and services with own work force

□ proposer will purchase goods directly from the manufacturer or other supplier

19. Name of State where your Home Office/Headquarters is located:

If not Texas, does the state have preferential treatment on bids □ Yes □ No

If Yes, what PERCENTAGE: _______________%

Does Your Company Employ 500 Or More Persons in Texas? □ Yes □ No

20. What is your Unique Entity ID (previously known as DUNS #, if applicable)? ___________________________

I ATTEST THAT I HAVE ANSWERED THE QUESTIONS REGARDING COMPANY INFORMATION TRUTHFULLY AND TO THE BEST OF MY

KNOWLEDGE.

CORPORATE OFFICER’S SIGNATURE

PRINTED NAME

TITLE

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ANTITRUST CERTIFICATION STATEMENT

include with Form A

(Texas Government Code §2155.005)

I affirm under penalty of perjury of the laws of the State of Texas that:

1. I am duly authorized to execute this agreement/contract/proposal on my own behalf or on behalf of the company, corporation, firm, partnership or individual (Company) listed below;

2. In connection with this proposal, neither I nor any representative of the Company have violated any provision of the Texas Free Enterprise and Antitrust Act, Tex. Bus & Comm. Code Chapter 15;

3. In connection with this Proposal, neither I nor any representative of the Company have violated any federal antitrust law;

and

4. Neither I nor any representative of the Company have directly or indirectly communicated any of the contents of this proposal to a competitor of the Company or any other company, corporation, firm, partnership or individual engaged in the same line of business as the Company.

Company Name:

Company Address:

City, State, Zip Code:

Phone:

Facsimile:

Proposer Signature:

Proposer Printed Name:

Position with Company:

(IF DIFFERENT FROM ABOVE)

Official Authorizing Proposal

Corporate Officer’s Signature

Printed Name

Position with Company