7-FORM 5 - RESPONSIBLE VENDOR REVIEW FORM.pdf

Responsible Vendor Review Form

A contract can only be awarded to a “responsible vendor”. A responsible vendor has the capability in all respects to fully perform the contract requirements and the integrity and reliability that will assure good faith performance.

To assist in making this determination, Vendors responding to this Solicitation are required to fully and accurately answer each of the questions below. For each “Yes” answer to questions 1.1 through 1.8, Vendor must provide a detailed explanation and attach copies of any relevant document cited in the explanation. Answering “Yes” to questions 1.1 through 1.8 will not necessarily disqualify a Vendor from participating in this Solicitation. However, failure to provide additional information as requested by the

City of Tallahassee may disqualify a Vendor.

The City of Tallahassee (COT) will base its determination of a Vendor’s responsibility on: (a) information provided by Vendor in response to this form; (b) information provided elsewhere in a Vendor’s response to the Solicitation (including financial information) and (c) information obtained from independent research (including information COT obtains from the internet or third parties, including System for Award

Management (SAM)).

Vendors shall provide immediate written notice to COT if any time prior to contract execution, a Vendor learns that the information provided in connection with this form was erroneous when submitted or has become erroneous for reason of changed circumstances. Vendor must contact the Procurement Officer with any questions regarding this form.

1.0 Within the last ten (10) years, in the State of Florida or any State or Federal jurisdiction has the

Vendor or any of its officers, directors or owner:

1.1 Been, subject to a revocation, suspension, disbarment, administrative complaint, sanction, fine, adverse action, or disciplinary action relating to any business or professional permit, certification, and/or license?

☐ Yes

☐ No

1.2 Been suspended, debarred, or disqualified from any government contracting process or agreed to voluntary exclusion from any government procurement process?

☐ Yes

☐ No

1.3 Been subject to formal monitoring agreement or corrective action plan as part of a contract with a government entity?

☐ Yes

☐ No

1.4 Been subject to an indictment, administrative proceeding, civil action or judgment in connection with any government contract?

☐ Yes

☐ No

1.5 Had a government contract terminated for cause? ☐ Yes

☐ No

1.6 Been convicted of a crime related to governmental or nongovernmental contracting?

☐ Yes

☐ No

1.7 Been subject to governmental investigation relating to alleged violation of any statutory regulatory violation?

☐ Yes

☐ No

1.8 Had a judgement entered in a civil lawsuit based on an allegation of fraud?

☐ Yes

☐ No

2.0 Does the vendor have the necessary organization, experience, accounting and operational controls, and professional and technical skills to meet its obligations under the proposed contract with COT, taking into consideration all existing commercial and governmental business commitments?

☐ Yes

☐ No

3.0 General Information

Do you have an active State Term Contract (STC) or General

Administrative Services (GSA) Contract similar to the scope of services for this solicitation. If yes, provide an attachment with links to the contract(s)

☐ STC

☐ GSA

☐ Not Applicable

By my signature below, I certify that I am an authorized representative of the Vendor named below and that all of the information provided above is true and complete to the best of my knowledge.

Name and Title Vendor Name

Signature Date

RFP-111-25-KM