Affirmation and Disclosure Form_3-4-22.pdf
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- Solicitation number
- SRC0000020923
- Issued by
- Seneca County, Ohio
About this file
This document is an Affirmation and Disclosure Form required for a state and local contract opportunity with the Ohio Department of Natural Resources (ODNR), Division of Wildlife, for water well drilling services at the Willow Point Wildlife Area. The scope of work includes mobilization, site clearing and grading, well installation, and development of an 8" PVC water well. Mandatory site visits are required between June 3-14, 2024, and the contract will be awarded to the lowest responsive and responsible bidder. Bidders must submit the required form, and invoices must be submitted directly to Ohio Shared Services. The project is scheduled to commence upon approval of the purchase order, and the contract term is through the end of the current biennium.
The total contract value is not to exceed $###,###,###.##. The State of Ohio requires the use of Ohio-certified Minority Business Enterprises (MBE) and Encouraging Diversity, Growth and Equity (EDGE) vendors where applicable. No incumbent vendors or current contractors are listed, and the documents do not mention any existing infrastructure or technology that requires integration. The pricing and funding details for this contract opportunity are not explicitly provided in the given documents.
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Text version
AFFIRMATION AND DISCLOSURE FORM
Rev. 3/22 Page 1 of 2
Contractor affirms that Contractor has read and understands the applicable Executive Orders regarding the prohibitions of performance of offshore services, locating State data offshore in any way, or purchasing from Russian institutions or companies.
Contractor shall provide all the name(s) and location(s) where services under this Contract will be performed and where data is located in the spaces provided below or by attachment. Failure to provide this information may result in no award. If the Contractor will not be using subcontractors, indicate “Not
Applicable” in the appropriate spaces.
1. Principal location of business of Contractor:
(Address) (City, State, Zip)
Name/Principal location of business of subcontractor(s):
(Name) (Address, City, State, Zip)
2. Location where services will be performed by Contractor:
Name/Location where services will be performed by subcontractor(s):
Rev. 3/22 Page 2 of 2
3. Location where state data will be located, by Contractor:
Name/Location(s) where state data will be located by subcontractor(s):
Contractor affirms, understands, and agrees that Contractor and its subcontractors are under a duty to disclose to the State any change or shift in location of services performed by Contractor or its subcontractors before, during and after execution of any contract with the State. Contractor agrees it shall so notify the
State immediately of any such change or shift in location of its services. The State has the right to immediately terminate the contract, unless a duly signed waiver from the State has been attained to perform the services outside the United States.
On behalf of the Contractor, I acknowledge that I am duly authorized to execute this Affirmation and
Disclosure Form and have read and understand that this form is a part of any Contract that Contractor may enter into with the State and is incorporated therein.
By:
Contractor
Print Name:
Title:
Date:
File details come from the government source that posted it. Updated .