ESBD_383080_1731698257758_EXHIBIT D - HUB Form.pdf

ATTACHMENT D

HISTORICALLY UNDERUTILIZED BUSINESS (HUB) FORM

The Travis County Healthcare District’s policy is to include Historically Underutilized Businesses (HUBs) in its procurement process and to provide equal opportunities for HUB participation in the provision of supplies, services, equipment and construction projects required by the District. As such, the District seeks to ensure that a “good faith effort” is made to assist certified HUB vendors and contractors in its award of contracts and subcontracts.

To be considered as a “Certified HUB Contractor/Vendor”, the contractor/vendor must have been certified by and hold a current and valid certification from any of the following certifying agencies recognized by the District:

the Texas Building and Procurement Commission (State of Texas); City of Austin; and the Texas Unified Certification Program (TUCP), which includes six (6) certifying agencies.

Suggested directories to assist proposers in identifying potential HUBs to meet the District’s “good faith effort” requirement include: State: https://comptroller.texas.gov/purchasing/vendor/hub/;

City: http://www.austintexas.gov/department/purchasing ; and TUCP: https://www.txdot.gov/business/partnerships/tucp.html

Proposer HUB Declaration

Is your company certified as a HUB or an MBE/WBE/DBE source? Yes No. If yes,

1. Attach your certification to this form and return it in the proposal;

2. Identify the certification agency by checking all that apply;

State of Texas Comptroller HUB Program

City of Austin; Texas Unified Certification Program; and

3. Identify HUB Status (Gender & Ethnicity):

**Please complete page 2 - Disclosure of HUB Subcontractors**

Estimated percentage of the bid (proposal) that is to be subcontracted with Certified HUB sources: % https://comptroller.texas.gov/purchasing/vendor/hub/ http://www.austintexas.gov/department/purchasing https://www.txdot.gov/business/partnerships/tucp.html

ATTACHMENT D

HISTORICALLY UNDERUTILIZED BUSINESS (HUB) FORM

Disclosure of Subcontractors

Sub Company Name: EIN/VID #:

Address: City: State: Zip Code:

Contact: Phone No.: Fax No.: E-mail:

Subcontract Amount: Percentage: Description of Work:

Is the company a certified HUB?

□ Yes ☐ No Indicate Gender & Ethnicity:

Certifying Agency (Check all applicable):

State of Texas https://comptrolle r.texas.gov/purch asing/vendor/hub

/ (HUB) ☐

City of Austin http://www.austint exas.gov/departme nt/purchasing

(M/WBE) ☐

Texas Unified Certification Program https://www.txdot.gov/business/pa rtnerships/tucp.html ☐

Sub Company Name: EIN/VID #:

Address: City: State: Zip Code:

Contact: Phone No.: Fax No.: E-mail:

Subcontract Amount: Percentage: Description of Work:

Is the company a certified HUB?

□ Yes ☐ No

Indicate Gender & Ethnicity:

Certifying Agency (Check all applicable):

State of Texas https://comptrolle r.texas.gov/purch asing/vendor/hub

/ ☐ (HUB) ☐

City of Austin www.ci.austin.tx.us /purchase/default.h tm (M/WBE) ☐

Texas Unified Certification Program https://www.txdot.gov/business/pa rtnerships/tucp.html (DBE) ☐

Sub Company Name: EIN/VID #:

Address: City: State: Zip Code:

Contact: Phone No.: Fax No.: E-mail:

Subcontract Amount: Percentage: Description of Work:

Is the company a certified HUB?

□ Yes ☐ No

Indicate Gender & Ethnicity:

Certifying Agency (Check all applicable):

State of Texas https://comptrolle r.texas.gov/purch asing/vendor/hub

/ (HUB) ☐

City of Austin www.ci.austin.tx.us /purchase/default.h tm (M/WBE) ☐

Texas Unified Certification Program https://www.txdot.gov/business/pa rtnerships/tucp.html (DBE) ☐ http://www.ci.austin.tx.us/purchase/default.htm http://www.ci.austin.tx.us/purchase/default.htm http://www.ci.austin.tx.us/purchase/default.htm