Attachment_B_-_Certification_Forms.pdf

DEBARRED CONTRACTOR CERTIFICATION

Project: _________________________________________________

Please complete the following, and return this form with your bid. If subcontractors have been identified, please have each subcontractor complete a form to be returned with your bid. If subcontractors have not been identified at the time of bid submission, a certification will be required from each subcontractor prior to that subcontractor starting work on the job.

Contractor: FID or EIN Number:

License Number: Trade:

Address: Zip Code:

I, , as representative of , certify that this firm has not and will not award a subcontract, in connection with any contract awarded to it as a result of this bid, to any firm that has been debarred for noncompliance with the Federal Labor Standards, Title VI of the Civil Rights Act, Executive Order 11246, as amended, or any other Federal law.

Name (typed) Title

Signature Date

Telephone Number ( ) Fax Number ( )

E.O. 11246 CERTIFICATION

This certification is required pursuant to Executive Order 11246 and regulations at 41 CFR Part 60- 1.7(b). Each bidder or prospective prime contractor and any proposed subcontractor shall state as a part of the bid or negotiation of a contract whether it has participated in any previous contract or subcontract subject to the Equal Opportunity Clause; whether it has developed and has on file an affirmative action program pursuant to 41 CFR Part 60-2; and whether it has filed all reports due under the applicable filing requirements of E.O. 11246.

Please complete the following, indicating your past participation by striking out the appropriate word(s) found in the brackets [ ], and return this form with your bid. If subcontractors have been identified, please have each subcontractor complete a form to be returned with your bid. If subcontractors have not been identified at the time of bid submission, a certification will be required from each subcontractor prior to that subcontractor starting work on the job.

Contractor: FID or EIN Number:

Address: Zip Code:

I, , as representative of , certify that this firm [has/has not] participated in a previous contract or subcontract which was subject to E.O. 11246. I further certify that this firm [has/has not] developed an affirmative action program pursuant to 41 CFR Part 60-2 and [has/has not] submitted all reports due under the applicable filing requirements of E.O. 11246.

CERTIFICATION OF NONSEGREGATED FACILITIES

In order to comply with obligations under the Equal Opportunity Clause, a prime contractor and all subcontractors must insure that facilities provided for employees are provided in such a manner that segregation on the basis of race, color, religion or national origin can not result.

Please complete the following and return this form with your bid. If subcontractors have been identified, please have each subcontractor complete a form to be returned with your bid. If subcontractors have not been identified at the time of bid submission, a certification will be required from each subcontractor prior to that subcontractor starting work on the job.

Contractor: FID or EIN Number:

Address: Zip Code:

I, , as representative of , certify that this firm does not and will not provide or maintain any facilities for its employees at any of its establishments which are segregated by race, color, religion or national origin and does not and will not permit its employees to perform their services at any location, under its control, where segregated facilities are maintained.

I agree that a breach of this certification will be a violation of the Equal Opportunity Clause of this contract. I agree as a representative of this firm that the term "segregated facilities," as used herein, means waiting rooms, work areas, restaurants and other eating areas, locker rooms and other storage or dressing areas, parking lots, drinking fountains, recreation or entertainment areas, transportation, and housing facilities provided for employees which are segregated by explicit directive or because of habit, local custom or otherwise. I further agree as a representative of this firm that this firm will obtain a Certification of Nonsegregated Facilities from all subcontractors working on this job prior to said subcontractors beginning work on the job.