Attachment_X_Updated.docx

ATTACHMENT “X”

BIDDER QUALIFICATION AFFIDAVIT

State the true, exact, correct and complete name of the company, sole proprietorship, partnership, corporation, trade or fictitious name under which the Bidder does business and the address of the place of business.

Name of Bidder

Address of Bidder Phone No. of Bidder Bidder E-Mail Address

The correct name of the Company is: ______________________________________________

a. FEI/EIN number _________________________________________________________

b. Trade Mark Name: _______________________________________________________

The Bidder is (check one of the following):

( ) An Individual ( ) A Partnership ( ) Sole Proprietorship ( ) A Corporation ( ) Trade

Principal Office Address:

1. If Bidder is a corporation, answer the following:

Date of Incorporation:

State of Incorporation:

President’s Name:

Vice President Name: _________________________________________

Secretary Name:

Treasurer’s Name: _________________________________________

Name and address of Resident (Florida) Agent:

2. If Bidder is an individual proprietorship or a partnership, answer the following:

Date of Organization:

Name, Address and Ownership Units of all Partners:

State whether general or limited partnership

3. If Bidder is other than a sole proprietorship, corporation or partnership, describe the organization and give the name and address of principals

4. If Bidder or company is an operation under a fictitious name, submit evidence of compliance with the Florida Fictitious Name Statute.

5. How many years has your organization been in business under its present business name?__________

6. Indicate registration, license number or certificate numbers for the businesses or professions, which are the subject of the Proposal/Bid. Please attach certificate of competency and state registration._____________________________________________________________

7. State the names, telephone numbers and last known addresses of three (3) owners, individuals or representative of owners with the most knowledge of work which you have performed or goods you have provided, and to which you refer (government owners are preferred as references).

(name) (address) (phone number)

(name) (address) (phone number)

(name) (address) (phone number)

THE OFFEROR ACKNOWLEDGES AND UNDERSTANDS THAT THE INFORMATION CONTAINED IN RESPONSE TO THIS QUALIFICATIONS STATEMENT SHALL BE RELIED UPON BY THE CITY IN AWARDING THE CONTRACT AND SUCH INFORMATION IS WARRANTED BY OFFEROR TO BE TRUE. THE DISCOVERY OF ANY OMISSION OR MISSTATEMENT THAT MATERIALLY AFFECTS THE OFFEROR’S QUALIFICATIONS TO PERFORM UNDER THE CONTRACT SHALL CAUSE THE CITY TO REJECT THE BID OR PROPOSAL, AND IF AFTER THE AWARD TO CANCEL AND TERMINATE THE AWARD AND/OR CONTRACT.

BIDDER QUALIFICATION AFFIDAVIT

IFB 20/21-23 Classification & Compensation Study 00440-2

Name of Bidder

Signature of Authorized Representative (Affiant) Date

Printed or Typed Name and Title of Authorized Representative (Affiant)

STATE OF FLORIDA

COUNTY OF __________________

I HEREBY CERTIFY that on this day, before me, an officer duly authorized to administer oaths and take acknowledgments, personally appeared ________________________ { } who is personally known to me or { } who produced ________________________ as identification and acknowledged before me that s/he executed the same. Sworn and subscribed before me, by ______________________________________________ by means of { } physical presence or { } online notarization on the _____ day of _____________, 2023, the said person did take an oath and was first duly sworn by me, on oath, said person, further, deposing and saying that s/he has read the foregoing and that the statements and allegations contained herein are true and correct.

WITNESS my hand and official seal in the County and State last aforesaid this____day of ________________, 2023.

(Notary Public in and for the County and State Aforementioned)

SEAL My commission expires:

PLEASE COMPLETE AND SUBMIT WITH YOUR RFP RESPONSE

Failure to submit this form may be grounds for disqualification of your submittal

END OF SECTION

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