Affirmation and Disclosure Form_3-4-22.pdf
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- Solicitation number
- SRC0000018734
- Issued by
- Ottawa County, Ohio
About this file
This document is an Affirmation and Disclosure Form related to a state and local contract opportunity for the installation of CAT6 Ethernet throughout the East Harbor State Park LE Building in Marblehead, Ohio. The project requires the installation of 9 CAT6 Ethernet runs to wall plates in various rooms, with some rooms having up to 4 Ethernet jacks per plate. The vendor is responsible for all materials, demo, haul away, and site clean-up. The contract also includes the purchase, but not installation, of a 10U or larger wall mount rack, a 24-port patch panel, and a rack mount power distribution unit. The project contact for site visits is Lieutenant Chad German, and the contract will be awarded to the lowest responsive and responsible bidder. The contract is for work to be completed by June 1, 2024.
The contract includes preference for Veteran-Friendly Business Enterprises, as well as Buy Ohio and Buy American bid preferences. Invoices must be submitted directly to Ohio Shared Services, and the contract is only valid for goods and services received through June 30 of the applicable year, with a new purchase order required for any work after that date.
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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 .