Change Notice 1.pdf

ITQ Signature Page (Revised 6/28/2013) PENNSYLVANIA DEPARTMENT OF TRANSPORTATION Contract 357I01-

Invitation to Qualify: Appraisal Services (Complete in INK or TYPE only—DO NOT use pencil)

READ ALL Directions/Instructions in Exhibit “A” (attached) Before Completing this Page

APPRAISER MUST COMPLETE ALL APPLICABLE AREAS

COMPANY NAME AND ADDRESS

If SOLE PROPRIETOR is doing business as (d/b/a) another name, see instructions in Exhibit “A” attached.

FOR COMMONWEALTH USE ONLY

APPRAISER’S CONTACT PERSON

PHONE NUMBER

FAX NUMBER

FEDERAL IDENTIFICATION OR SOCIAL SECURITY NO.

Are you a Disadvantaged Business Enterprise certified by PENNDOT?

Yes No (If yes, Certification Number ) Are you a Small Diverse Business verified with the State of Pennsylvania?

Yes No

(If yes, Certification Number )

REQUIRED E-MAIL ADDRESS (It is mandatory for appraisers to have an active e-mail address and the capability to conduct e-business. An Appraiser will not be qualified for any category of work if the Appraiser fails to meet this requirement):

VENDOR NUMBER (All vendors must register with the Commonwealth at www.vendorregistration.state.pa.us):

Appraiser acknowledges any and all handwritten information by initialing/dating here. INITIAL The Appraiser’s authorized signatory must initial and date where indicated at right.

DATE

This contract consists of the following provisions and exhibits. The Appraiser shall comply with all provisions as listed below:

1) The following provisions applicable to this contract, all of which are incorporated by reference as though physically attached to this contract: Offset Clause, amended 4-16-99, and any subsequent amendments to Management Directive 215.9 from which this provision is derived; Contractor Integrity Provisions, amended 12-20-91, and any subsequent amendments to Management Directive 215.8 from which these provisions are derived; The Provisions Concerning the Americans with Disabilities Act, amended 1-16-01, and any subsequent amendments to Management Directive 215.12 from which these provisions are derived; Commonwealth Nondiscrimination/Sexual Harassment Clause, dated 6-30-99, and any subsequent amendments to Management Directive 215.16 from which this provision is derived; Federal Nondiscrimination and Equal Employment Opportunity Clause (All Federal Aid Contracts), dated 1-76, and any subsequent amendments; Appraiser Responsibility Provisions, amended 4-16-99, and any subsequent amendments to Management Directive 215.9 from which this provision is derived; Audit Clause to Be Used in Agreements with Entities Receiving Federal Awards from the Commonwealth, dated 12-03-03 and any subsequent amendments to Management Directive 325.9 from which this provision is derived; and Travel Policies, amended 3-21-08, and any subsequent amendments to Management Directive 230.10 from which these provisions are derived; and,

2) The Terms and Conditions attached as Exhibit “A” to this contract; and,

3) The Lobbying Certification Form, Disclosure of Lobbying Activities Form (if applicable), and Insurance Requirements attached as Exhibit “B” to this contract; and,

4) Qualification Information (Qualification Application, Location of Service, and Client Reference Survey Forms) attached as Exhibit “C” to this contract; and,

5) The Qualification Application Update Form attached as Exhibit “E” to this contract; and

6) District Right-of-Way Administrators attached as Exhibit “F” to this contract; and

7) Confirmation of Service form attached as Exhibit “G” to this contract; and

8) Questions and Answers (available after 5/7/2008) attached as Exhibit “H” to this contract.

The Commonwealth will notify the Appraiser when this contract is a fully executed contract and the effective dates thereto.

APPRAISER’S SIGNATURE, DATE AND TITLE REQUIRED (IN INK)

CORPORATION:

CHAIRMAN, PRESIDENT, VICE PRESIDENT, X

SR. VICE PRESIDENT, EXEC. VICE PRESIDENT, SIGNATURE DATE TITLE

ASST. VICE PRESIDENT, CEO, OR COO

SOLE PROPRIETORSHIP:

OWNER ONLY: X OWNER

SIGNATURE DATE TITLE

PARTNERSHIP:

ONE GENERAL PARTNER ONLY: X _ GENERAL PARTNER

SIGNATURE DATE TITLE

LIMITED LIABILITY COMPANY X MEMBER/MANAGER

MEMBER OR MANAGER SIGNATURE DATE TITLE

COMMONWEALTH USE ONLY:

1. AGENCY HEAD OR DESIGNEE

X

SIGNATURE DATE

2. PENNDOT OFFICE OF CHIEF COUNSEL (Approved as to Legality and Form)

X SIGNATURE

DATE

3. OFFICE OF THE COMPTROLLER (Approved as to Fiscal Responsibility, Budgetary Appropriateness and Availability of Funds)

4. GENERAL COUNSEL (Approved as to Legality and Form)

X SIGNATURE

DATE

5. ATTORNEY GENERAL (Approved as to Legality and Form) http://www.vendorregistration.state.pa.us/