5-Vendor Questionnaire - CABs.docx

VENDOR QUESTIONNAIRE

QUOTES

The completed Vendor Questionnaire should be submitted with the solicitation response. If not submitted with solicitation response, it must be submitted within three business days after County’s written request. Failure to timely submit this form may result in the Vendor being deemed nonresponsive.

If a response requires additional information, the Vendor should upload a written detailed response with submittal; each response should be labeled to match the question number.

1. Legal business name: Click or tap here to enter text.

2. Doing Business As/Fictitious Name (if applicable): Click or tap here to enter text.

3. Federal Employer I.D. No. (FEIN): Click or tap here to enter text.

4. Office location responsible for this project: Click or tap here to enter text.

5. Telephone No.: Click or tap here to enter text.

6. Generic e-mail for purchase orders: Click or tap here to enter text.

(Broward County auto distributes purchase orders; to ensure Vendor receives purchase orders, a company accessible e-mail address is suggested.)

7. Authorized Contact(s):

8. Has Vendor, or any of its principals, officers, or predecessor organization(s), been debarred or suspended by any government entity within the last three years? If yes, specify details in an attached written response. ☐ Yes ☐ No

9. Affirm Vendor is currently authorized by the manufacturer as a dealer/seller of the product(s) offered, and the warranty offered is the manufacturer’s warranty with Broward County recorded as the original purchaser? ☐ Yes ☐ No ☐ N/A (if service)

10. Will Vendor extend the same price, terms, and conditions to other governmental entities during the period covered by this contract? ☐ Yes ☐ No

11. Does Vendor accept a Visa credit card as payment from Broward County, with no additional fees or change to bid price? Procurement Contract must be approved and designated for procurement card (p-card) by Director of Purchasing for use prior to ordering. ☐ Yes ☐ No

12. Non-Collusion Certification: The Vendor must disclose, to their best knowledge, any Broward County officer or employee, or any relative of any such officer or employee as defined in Section 112.3135(1)(d), Florida Statutes, who is an officer or director of, or has a material interest in, the Vendor’s business, who is in a position to influence this procurement. Any Broward County officer or employee who has any input into the writing of specifications or requirements, solicitation of offers, decision to award, evaluation of offers, or any other activity pertinent to this procurement is presumed, for purposes hereof, to be in a position to influence this procurement. Failure of a Vendor to disclose any relationship described herein shall be reason for debarment in accordance with the provisions of the Broward County Procurement Code. Select One:

☐ The Vendor certifies that this offer is made independently and free from collusion; or

☐ The Vendor is disclosing names of officers or employees who have a material interest in this procurement and is in a position to influence this procurement. The Vendor must include a list of name(s) and each relationship with its submittal.

13. Participation in Solicitation Development: By submission of this solicitation response, the Vendor certifies as follows (select one):

☐ I have not participated in the preparation or drafting of any language, scope, or specification that would provide Vendor or any affiliate an unfair advantage of securing this solicitation.

☐ I have provided information regarding the specifications and/or products listed in this solicitation. If this box is checked, provide the following:

Name /Division information was provided to: Click or tap here to enter text.

Title: Click or tap here to enter text.

Date information provided: Click or tap here to enter text.

For what purpose was the information provided? Click or tap here to enter text.

14. Drug-Free Workplace Certification: In accordance with Section 287.087, Florida Statutes, whenever two or more submittals are tied, a submittal received from a Vendor that certifies it has implemented a drug-free workplace program shall be given preference in the award process.

The Vendor hereby certifies that: (only if Vendor is certifying it currently complies, check box)

☐ The Vendor hereby certifies that it has established a drug-free workplace program in accordance with the requirements of Section 287.087, Florida Statutes, (“Preference to businesses with drug-free workplace programs.”)

The County reserves the right to obtain vendor references as part of the County’s responsibility review process. If requested by the County, references must be submitted within three business days after County’s written request.

I hereby certify the information provided in this Vendor Questionnaire is true and correct*:

Vendor Name: Click or tap here to enter text.

Signature: ______________________________ Printed Name: Click or tap here to enter text.

Title: Click or tap here to enter text.

Date: Click or tap to enter a date.

* I certify that I am authorized to sign this solicitation response on behalf of the Vendor as indicated in Certificate as to Corporate Principal, designation letter by Director/Corporate Officer, or other business authorization to bind on behalf of the Vendor. As the Vendor's authorized representative, I attest that any and all statements, oral, written or otherwise, made in support of the Vendor's response are accurate, true, and correct. I also acknowledge that inaccurate, untruthful, or incorrect statements made in support of the Vendor's response may be used by the County as a basis for rejection, rescission of the award, or termination of the contract, and may also serve as the basis for debarment of the Vendor pursuant to Part XI of the Broward County Procurement Code. I certify that the Vendor's response is made without prior understanding, agreement, or connection with any corporation, firm, or person submitting a response for the same items/services, and is in all respects fair and without collusion or fraud. I also certify that the Vendor agrees to abide by all terms and conditions of this solicitation.

Form Date 07/15/25