Attachment 5 - ITB-cover-submittal-form.docx

ATTACHMENT 6

Bid Submission Cover Sheet Revised March 7, 2024

PROJECT INFORMATION

ITB NUMBER:

PROJECT NAME:

BIDDER INFORMATION

Company Name:

Address:

Tax ID:

Alaska Business License #:

CONTACT INFORMATION

Provide contact information for the individual that can be contacted for clarification regarding this bid:

Name

Title

Address

Email

Telephone

Procurement Officer Note: REVISE OR DELETE AS REQUIRED.

ADDENDA ACKNOWLEDGEMENT

The bidder acknowledges receipt of the following amendments and has incorporated the requirements of such amendments into their bid. Failure to identify and sign for all amendments may subject the bidder to disqualification. The bidder must list all amendments (by number), then initial and date to confirm that you have received and incorporated them into your bid (add more rows as necessary).

CERTIFICATIONS

* Failure to answer or answering “False” may be grounds for disqualification. For any “False” responses, provide clarification (up to 250 word maximum for each “False” clarification) below (add rows as necessary).

CONFLICT OF INTEREST STATEMENT

Indicate below whether or not the firm or any individuals that will work on the contract has a possible conflict of interest (e.g., currently employed by the State of Alaska or formerly employed by the State of Alaska within the past two years) and, if so, the nature of that conflict. The procurement officer reserves the right to consider a bid non-responsive and reject it or cancel the award if any interest disclosed from any source could either give the appearance of a conflict or cause speculation as to the objectivity services to be provided by the bidder.

* Failure to answer may be grounds for disqualification.

If “Yes”, please provide additional information regarding the nature of that conflict:

FEDERAL REQUIREMENTS

Indicate below all known federal requirements that apply to the bid, it’s evaluation, or the resulting contract:

ALASKA PREFERENCES

If you wish to claim any Alaska Preferences, please complete the Alaska Bidder Preference Certification Form that follows the below signature section.

SIGNATURE

This bid must be signed by a company officer empowered to bind the company.

Printed Name

Title

Date

Signature

ALASKA BIDDER PREFERENCE CERTIFICATION

AS 36.30.321(A) / AS 36.30.990(2)

BUSINESS NAME: Click or tap here to enter text.

Please list any additional Alaska Preferences below that you believe your firm qualifies for.

1. 2. 3. 4. 5. 6.

To qualify for and claim the Alaska Bidder Preference you must answer YES to all questions below in the Alaska Bidder Preference Questions section. To qualify for and claim the Alaska Veteran Preference, you must answer YES to these questions as well as answer YES to all the questions in the Alaska Veteran Preference section. A signed copy of this form must be included with your bid no later than the deadline set for receipt of bids.

If you are submitting a bid as a JOINT VENTURE, all members of the joint venture must complete and submit this form before the deadline set for receipt of bids. AS 36.30.990(2)(E)

If the procuring agency is unable to verify a response, the preference may not be applied. Knowingly or intentionally making false or misleading statements on this form, whether it succeeds in deceiving or misleading, constitutes misrepresentation per AS 36.30.687 and may result in criminal penalties.

Alaska Bidder Preference Questions:

1) Does your business hold a current Alaska business license per AS 36.30.990(2)(A)?

☐ YES ☐ NO

If YES, enter your current Alaska business license number: Click or tap here to enter text.

If YES, please complete the following information:

A. Place of Business

“Place of business” is defined as a location at which normal business activities are conducted, services are rendered, or goods are made, stored, or processed; a post office box, mail drop, telephone, or answering service does not, by itself, constitute a place of business per 2 AAC 12.990(b)(3).

Do you certify that the Place of Business described in Question 3A meets this definition?

☐ YES ☐ NO

B. The bidder, or at least one employee of the bidder, must be a resident of the state under AS 16.05.415(a) per 2 AAC 12.990(b)(7).

1) Do you certify that the bidder OR at least one employee of the bidder is physically present in the state with the intent to remain in Alaska indefinitely and to make a home in the state per AS 16.05.415(a)(1)?

☐ YES ☐ NO

2) Do you certify that that the resident(s) used to meet this requirement has maintained their domicile in Alaska for the 12 consecutive months immediately preceding the deadline set for receipt of bids or proposals per AS 16.05.415(a)(2)?

☐ YES ☐ NO

3) Do you certify that the resident(s) used to meet this requirement is claiming residency ONLY in the state of Alaska per AS 16.05.415(a)(3)?

☐ YES ☐ NO

4) Do you certify that the resident(s) used to meet this requirement is NOT obtaining benefits under a claim of residency in another state, territory, or country per AS 16.05.415(a)(4)?

If YES, enter your current Alaska corporate entity number: Click or tap here to enter text.

Please identify each member by name: Click or tap here to enter text.

Please identify each member by name: Click or tap here to enter text.

Alaska Veteran Preference Questions:

1. Per AS 36.30.321(F), is your business (CHOOSE ONE):

A. A sole proprietorship owned by an Alaska veteran?

Per AS 36.30.321(F)(3) “Alaska veteran” is defined as an individual who:

(A) Served in the

(i) Armed forces of the United States, including a reserve unity of the United States armed forces; or

(ii) Alaska Territorial Guard, the Alaska Army National Guard, the Alaska Air Nations Guard, or the Alaska Naval Militia; and

(B) Was separated from service under a condition that was not dishonorable.

Do you certify that the individual(s) indicated in Question 1A, 1B, 1C, or 1D meet this definition and can provide documentation of their service and discharge if necessary?

☐ YES ☐ NO

SIGNATURE

By signature below, I certify under penalty of law that I am an authorized representative of Click or tap here to enter text. and all information on this form is true and correct to the best of my knowledge.

Printed Name

Title

Date

Signature image1.png