Attached Forms.pdf

Florida Statutes:

287.135

STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION

VENDOR CERTIFICATION REGARDING

SCRUTINIZED COMPANIES LISTS

375-030-60

PROCUREMENT

OGC – 06/18

Respondent Vendor Name:

Vendor FEIN:

Vendor’s Authorized Representative Name and Title:

Address:

City: State: Zip:

Phone Number:

Email Address:

Section 287.135, Florida Statutes prohibits a company from bidding on, submitting a proposal for, or entering into or renewing a contract for goods or services of any amount if, at the time of contracting or renewal, the company is on the Scrutinized Companies that Boycott Israel List, created pursuant to Section 215.4725, Florida Statutes, or is engaged in a boycott of Israel. Section 287.135, Florida Statutes, also prohibits a company from bidding on, submitting a proposal for, or entering into or renewing a contract for goods or services of $1,000,000 or more, that are on either the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector Lists which were created pursuant to s. 215.473, Florida Statutes.

As the person authorized to sign on behalf of Respondent, I hereby certify that the company identified above in the section entitled “Respondent Vendor Name” is not listed on either the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List, or the Scrutinized Companies that Boycott Israel List. I further certify that the company is not engaged in a boycott of Israel. I understand that pursuant to section 287.135, Florida Statutes, the submission of a false certification may subject company to civil penalties, attorney’s fees, and/or costs.

Certified By:

who is authorized to sign on behalf of the above referenced company.

Authorized Signature Print Name and Title:

Date:

STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION

MBE PLANNED UTILIZATION

375-040-24

PROCUREMENT

03/17

PROCUREMENT NO. DOT-ITB-25-4007-CO FINANCIAL PROJECT NO. 453825-1-93-01 &

VARIOUS

(DEPARTMENT USE ONLY)

DESCRIPTION: CLOUD BASED ARTERIAL MANAGEMENT (CBAM) REGIONAL PLATFORM FOR TREASURE

COAST FOR FLORIDA DEPARTMENT OF TRANSPORTATION - DISTRICT FOUR

I, , (name) (title) of plan to subcontract at least % (percent) of the project costs on the above referenced project to Minority

Business Enterprises.

If I have indicated above that a portion of the project costs will be subcontracted to MBE(s), the firms considered as proposed subconsultants/contractors and the types of services or commodities to be subcontracted are as follows:

MBE SUBCONSULTANTS/CONTRACTORS TYPES OF SERVICES/COMMODITIES

I understand that I will need to submit Minority Business Enterprises (MBE) payment certification forms to the Department for reporting purposes only.

Signed:

Title:

E-VERIFY

375-031-06

PROCUREMENT

OGC – 10/21

Contract No: DOT-ITB-25-4007-CO

Financial Project No(s): 453825-1-93-01 & VARIOUS

Project Description: CLOUD BASED ARTERIAL MANAGEMENT (CBAM) REGIONAL PLATFORM FOR

TREASURE COAST FOR FLORIDA DEPARTMENT OF TRANSPORTATION - DISTRICT FOUR

In accordance with the contract, the Vendor/Consultant/Contractor hereby acknowledges and certifies compliance with Section 448.095, Florida Statutes. The Vendor/Consultant/Contractor shall register with and use the E-Verify system to verify the work authorization status of all newly hired employees. The Vendor/Consultant/Contractor shall utilize the U.S. Department of Homeland Security’s E-Verify system, in accordance with the terms governing use of the system. The Vendor/Consultant/Contractor shall comply with Section 448.095, Florida Statutes, for the duration of the contract term, including any extensions or renewal periods.

Company/Firm:

Authorized Signature:

Title:

BID OPPORTUNITY LIST FOR COMMODITIES & CONTRACTUAL

SERVICES

375-040-62

PROCUREMENT

01/16

Prime Contractor:

Address/Phone Number:

Procurement Number: DOT-ITB-25-4007-CO

49 CFR Part 26.11 The list is intended to be a listing of all firms that are participating, or attempting to participate, on DOT-assisted contracts. The list must include all firms that bid on prime contracts, or bid or quote subcontracts and supplies materials on DOT-assisted projects, including both DBEs and non-DBEs. This list must include all subcontractors contacting you and expressing an interest in teaming with you on a specific DOT-assisted project. Prime contractors must provide information for Numbers 1, 2, 3 and 4, and should provide any information they have available on Numbers 5, 6, and 7 for themselves, and their subcontractors.

1. Federal Tax ID Number: 6. DBE 7. Annual Gross Receipts

2. Firm Name: Non-DBE Less than $1 million

3. Phone: Between $1 - $5 million

4. Address: Between $5 - $10 million

Between $10 - $15 million More than $15 million

5. Year Firm Established:

1. Federal Tax ID Number: 6. DBE 7. Annual Gross Receipts

2. Firm Name: Non-DBE Less than $1 million

3. Phone: Between $1 - $5 million

4. Address: Between $5 - $10 million

Between $10 - $15 million More than $15 million

5. Year Firm Established:

1. Federal Tax ID Number: 6. DBE 7. Annual Gross Receipts

2. Firm Name: Non-DBE Less than $1 million

3. Phone: Between $1 - $5 million

4. Address: Between $5 - $10 million

Between $10 - $15 million More than $15 million

5. Year Firm Established:

1. Federal Tax ID Number: 6. DBE 7. Annual Gross Receipts

2. Firm Name: Non-DBE Less than $1 million

3. Phone: Between $1 - $5 million

4. Address: Between $5 - $10 million

Between $10 - $15 million More than $15 million

5. Year Firm Established:

AS APPLICABLE, PLEASE SUBMIT THIS FORM WITH YOUR: BID SHEET (Invitation to Bid – ITB) PRICE PROPOSAL (Request for Proposal – RFP) REPLY (Invitation to Negotiate – ITN)

DRUG-FREE WORKPLACE PROGRAM CERTIFICATION

375-040-18

PROCUREMENT

03/17

287.087 Preference to businesses with drug-free workplace programs. --Whenever two or more bids, proposals, or replies that are equal with respect to price, quality, and service are received by the state or by any political subdivision for the procurement of commodities or contractual services, a bid, proposal, or reply received from a business that certifies that it has implemented a drug-free workplace program shall be given preference in the award process. In order to have a drug-free workplace program, a business shall:

(1) Publish a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the workplace and specifying the actions that will be taken against employees for violations of such prohibition.

(2) Inform employees about the dangers of drug abuse in the workplace, the business's policy of maintaining a drug-free workplace, any available drug counseling, rehabilitation, and employee assistance programs, and the penalties that may be imposed upon employees for drug abuse violations.

(3) Give each employee engaged in providing the commodities or contractual services that are under bid a copy of the statement specified in subsection (1).

(4) In the statement specified in subsection (1), notify the employees that, as a condition of working on the commodities or contractual services that are under bid, the employee will abide by the terms of the statement and will notify the employer of any conviction of, or plea of guilty or nolo contendere to, any violation of Chapter 893 or of any controlled substance law of the United States or any state, for a violation occurring in the workplace no later than 5 days after such conviction.

(5) Impose a sanction on, or require the satisfactory participation in a drug abuse assistance or rehabilitation program if such is available in the employee's community by, any employee who is so convicted.

(6) Make a good faith effort to continue to maintain a drug-free workplace through implementation of this section.

Does the individual responding to this solicitation certify that their firm has implemented a drug-free workplace program in accordance with the provision of Section 287.087, Florida Statutes, as stated above?

YES

NO

NAME OF BUSINESS: