APPENDIX C _ Required Forms.pdf

APPENDIX C

REQUIRED FORMS

CONTRACTOR AFFIDAVIT AND AGREEMENT

By executing this affidavit, the undersigned Contractor verifies its compliance with O.C.G.A. § 13- 10-91, stating affirmatively that the individual, firm or corporation which is engaged in the physical performance for services on behalf of Clayton County Board of Education. (name of public employer), has registered with, is authorized to use and uses the federal work authorization program commonly known as E-Verify, or any subsequent replacement program, in accordance with the applicable provisions and deadlines established in O.C.G.A. § 13-10-91. Furthermore, the undersigned Contractor will continue to use the federal work authorization program throughout the contract period and the undersigned Contractor will contract for the physical performance of services in satisfaction of such contract only with sub-Contractors who present an affidavit to the Contractor with the information required by O.C.G.A. § 13-10-91(b). Contractor hereby attests that its federal work authorization user identification number and date of authorization are as follows:

Federal Work Authorization User Identification Number

Date of Authorization

Name of Contractor

RFP 011-24 Network Infrastructure Name of Project

Clayton County Board of Education Name of Public Employer

I hereby declare under penalty of perjury that the foregoing is true and correct.

Executed on , 20 in (city), (state).

Signature of Authorized Officer or Agent

Printed Name and Title of Authorized Officer or Agent

SUBSCRIBED AND SWORN BEFORE ME ON THIS THE DAY OF .

20 .

NOTARY PUBLIC

My Commission Expires:

CCPS, Req. Form 1, 08/2016

SUB-CONTRACTOR AFFIDAVIT AND AGREEMENT

By executing this affidavit, the undersigned Sub-contractor verifies its compliance with O.C.G.A. § 13-10-91, stating affirmatively that the individual, firm or corporation which is engaged in the physical performance of services under a contract with ________________________ (name of Contractor) on behalf of the Clayton County Board of Education has registered with, is authorized to use and uses the federal work authorization program commonly known as E-Verify, or any subsequent replacement program, in accordance with the applicable provisions and deadlines established in O.C.G.A. § 13-10-91. Furthermore, the undersigned Sub-contractor will continue to use the federal work authorization program throughout the contract period and the undersigned Sub-contractor will contract for the physical performance of services in satisfaction of such contract only with Sub-Sub-Contractors who present an affidavit to the Sub-contractor with the information required by O.C.G.A. § 13-10-91(b). Additionally, the undersigned Sub-contractor will forward notice of the receipt of an affidavit from a Sub-Sub-contractor to the Contractor within five business days of receipt. If the undersigned Sub-contractor receives notice of receipt of an affidavit from any Sub-Sub-contractor that has contracted with a Sub-Sub-contractor to forward, within five business days of receipt, a copy of such notice to the Contractor. Sub-contractor hereby attests that its federal work authorization user identification number and date of authorization are as follows:

Federal Work Authorization User Identification Number Date of Authorization

Name of Contractor

RFP 011-24 Network Infrastructure Name of Project

Clayton County Board of Education Name of Public Employer

I hereby declare under penalty of perjury that the foregoing is true and correct.

Executed on , 20 in (city), (state).

Signature of Authorized Officer or Agent Printed Name and Title of Authorized Officer or Agent

SUBSCRIBED AND SWORN BEFORE ME ON THIS THE _____DAY OF 20___.

NOTARY PUBLIC

My Commission Expires:

SUB-SUBCONTRACTOR AFFIDAVIT AND AGREEMENT

By executing this affidavit, the undersigned Sub-contractor verifies its compliance with O.C.G.A. § 13-10-91, stating affirmatively that the individual, firm or corporation which is engaged in the physical performance of services under a contract with ________________________ (name of Contractor) on behalf of the Clayton County Board of Education has registered with, is authorized to use and uses the federal work authorization program commonly known as E-Verify, or any subsequent replacement program, in accordance with the applicable provisions and deadlines established in O.C.G.A. § 13-10-91. Furthermore, the undersigned Sub-contractor will continue to use the federal work authorization program throughout the contract period and the undersigned Sub-contractor will contract for the physical performance of services in satisfaction of such contract only with Sub-Sub-Contractors who present an affidavit to the Sub-contractor with the information required by O.C.G.A. § 13-10-91(b). Additionally, the undersigned Sub-contractor will forward notice of the receipt of an affidavit from a Sub-Sub-contractor to the Contractor within five business days of receipt. If the undersigned Sub-contractor receives notice of receipt of an affidavit from any Sub-Sub-contractor that has contracted with a Sub-Sub-contractor to forward, within five business days of receipt, a copy of such notice to the Contractor. Sub-contractor hereby attests that its federal work authorization user identification number and date of authorization are as follows:

Federal Work Authorization User Identification Number Date of Authorization

Name of Contractor

RFP 011-24 Network Infrastructure Name of Project

Clayton County Board of Education Name of Public Employer

I hereby declare under penalty of perjury that the foregoing is true and correct.

Executed on , 20 in (city), (state).

Signature of Authorized Officer or Agent Printed Name and Title of Authorized Officer or Agent

SUBSCRIBED AND SWORN BEFORE ME ON THIS THE _____DAY OF 20___.

NOTARY PUBLIC

My Commission Expires:

CCPS, Req. Form 3, 8/2016

CCPS, Req. Form 4, 08/2016

RFP 011-24

NETWORK INFRASTRUCTURE

PROPONENT REPRESENTATIONS AND DECLARATIONS

This Acknowledgement of Representations and Declarations and Agreement must be properly signed and notarized, and returned with Proponents response to this RFP.

1. Anti-Lobbying Provision. All respondents, including agents, personnel, representatives, lobbyists, attorneys and proposed partner(s), subcontractor(s) or joint venturer(s), will refrain, under penalty of the respondent’s disqualification, from direct or indirect contact for the purpose of influencing the selection or creating bias in the selection process with any person who may play a part in the selection process.

2. Certification of Independent Price Determination/Non-Collusion. Collusion and other anticompetitive practices among offerors are prohibited by city, state and federal laws. All Respondents shall identify a person having authority to sign for the Respondent who shall certify, in writing, as follows:

“I certify that this bid/proposal is made without prior understanding, agreement, or connection with any corporation, firm, or person submitting a bid or offer for the same supplies, labor, services, construction, materials or equipment to be furnished or professional or consultant services, and is in all respects fair and without collusion or fraud. I understand collusive bidding is a violation of city, state and federal law and can result in fines, prison sentences, and civil damages awards. By signing this document, I agree to abide by all conditions of this solicitation and offer and certify that I am authorized to sign for this Respondent/Offeror.”

3. Prohibition on Kickbacks or Gratuities/Non-Gratuity. The undersigned acknowledges the following prohibitions on kickbacks and gratuities:

a. It is unethical for any person to offer, give or agree to give any employee or former employee a gratuity or an offer of employment in connection with any decision, approval, disapproval, recommendation, preparation or any part of a program requirement or a purchase request, influencing the content of any specification or procurement standard, rendering of advice, investigation, auditing or in any other advisory capacity in any proceeding or application, request for ruling, determination, claim or controversy or other particular matter pertaining to any program requirement or a contract or subcontract or to any solicitation or proposal therefor.

b. It is unethical for any employee or former employee to solicit, demand, accept or agree to accept from another person a gratuity or an offer of employment in connection with any decision, approval, disapproval, recommendation, preparation or any part of a program requirement or a purchase request, influencing the content of any specification or procurement standard, rendering of advice, content of any specification or procurement standard, rendering of advice, investigation, auditing or in any other advisory capacity in any proceeding or application, request for ruling, determination, claim or controversy

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c. It is also unethical for any payment, gratuity or offer of employment to be made by or on behalf of a subcontractor under a contract to the prime Contractor or higher tier subcontractor or any person associated therewith as an inducement for the award of a subcontract or order.

4. Debarment. The undersigned Service Provider/Contractor provides this assurance and certification that they are not currently debarred from submitting proposals or proposals on contracts by any agency in the State of Georgia and the federal government, nor are they an agent of any person or entity that is currently debarred from submitting proposals on contracts by any agency of the State of Georgia or the federal government.

5. Covenant of Non-Discrimination. The undersigned understands that it is the policy of CCPS to promote full and equal business opportunity for all persons doing business with the CCPS. The undersigned covenants that we have not discriminated, on the basis of race, color, religion, sex, gender, national origin or ethnicity, with regard to prime contracting, subcontracting or partnering opportunities.

6. Small Local Business Enterprise (SLBE) Program. The undersigned Proponent hereby state that they have read and understand the requirements and conditions as set forth in the CCPS Inclusivity in Purchasing, Small Local Business Enterprise Program, and that reasonable effort were made to support the CCPS in providing the maximum practicable opportunity for the utilization of SLBEs consistent with the efficient and economical performance of this contract. The Proponent and any subcontractors shall file compliance reports at reasonable times and intervals with CCPS in the form and to the extent prescribed

by. Compliance reports filed at such times as directed shall contain information as to the employment practices, policies, programs and statistics of Proponents and their subcontractors/suppliers. The undersigned understands and agrees that if any of the statements and representations are made by the Proponent knowing them to be false, or if there is a failure of the successful Proponent to implement any of the stated agreements, intentions, objectives, goals and commitments set forth herein without prior approval of CCPS, then in any such events the Proponent’s act or failure to act shall constitute a material breach of contract, entitling CCPS to terminate the Contract for default. The right to so terminate shall be in addition to, and not in lieu of, any other rights and remedies CCPS may have for other defaults under the Contract. Additionally, Proponent will be subject to the loss of any future contract awards by the CCPS for a period of one year.

7. Certify Satisfaction of all Underlying Obligations. (If Applicable). If a Contract is awarded through this solicitation, then such Contractor should know that before final payment is made to a Contractor by CCPS, the Contractor shall certify to CCPS in writing, in a form satisfactory to CCPS, that all subcontractors, materialmen suppliers and similar firms or persons involved in the CCPS contract have been paid in full at the time of final payment to the Contractor by CCPS or will be paid in full utilizing the monies constituting final payment to the Contractor.

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8. Proponent Declarations:

a. I, the undersigned, have carefully examined and fully understand the CCPS General

Terms and Conditions and this solicitation in its entirety, including all required forms and Proponent Representations, and agree to conform with every requirement. I certify that I am legally authorized to make the statements and representations herein and sign this quote for the Proponent. Signing this form affirms that the Original Request for Proposal Document has not been altered in any way.

b. I certify that this offer is made without prior understanding, agreement, or connection with any corporation, firm, or person submitting an offer for the same supplies, services, construction, or professional or consultant services, and is in all respects fair and without collusion or fraud. I understand collusive bidding is a violation of city, state and federal law and can result in fines, prison sentences, and civil damages awards. I agree to abide by all conditions of this solicitation and offer and certify that I am authorized to sign for this Proponent.

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Sign here if you are an individual:

Printed Name: ____________________________ Signature: _______________________________ Date: ____________________ Subscribed and sworn to or affirmed by ______________________ (name) this ___ day of _____________, 20__.

Notary Public of _____________(state)

My commission expires: ________________

Sign here if you are an authorized representative of a responding entity or partnership:

Printed Name of Entity or Partnership: ______________________________

Signature of authorized representative: ______________________________ Title: ___________________________________________________________ Date: __________________, 20___

Subscribed and sworn to or affirmed by __________________________________ (name), as the _____________________ (title) of ____________________________ (entity or partnership name) this _____ day of ___________, 20___.

Notary Public of _____________ (state)

My commission expires: _____________

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CCPS, Req. Form 5, 08/2016

REFERENCE AND RELEASE FORM

Please provide the information and contact person who will verify Contractor’s experience and ability to perform the services listed in the RFP. Submission of this form grants CCPS the authority to contact each reference listed.

Proponent Name: ___________________________________________________________ Project Name:

Project Number:

Contract Period:

Company Name:

Contact Person: (Name and Title)

Email Address: Address

Telephone Number:

Fax Number:

City State Zip Code

Project Number:

Contract Period:

Company Name:

Contact Person: (Name and Title)

Email Address: Address

Telephone Number:

Contract Period:

Company Name:

Contact Person: (Name and Title)

Email Address: Address

Telephone Number:

Contract Period:

Company Name:

Contact Person: (Name and Title)

Email Address: Address

Telephone Number:

Authorized Signature: ________________________ _______ Date: _____________________