ESBD_387539_1734731272515_Attachment A - Execution of Proposal.pdf

ATTACHMENT A – EXECUTION OF PROPOSAL

RFQ No. 781-5-03287

(It is mandatory to complete, sign, and submit this form with the proposal.)

1. RESPONDENT INFORMATION

Federal Employer ID No.: _____________ Texas Tax ID No.: _____________

Entity Name: ________________________________________________

Street Address: ________________________________________________

City/State/Zip Code: _________________________________________

Telephone No.: _________________ Facsimile No.: _________________

Website URL: ________________________________________________

EXECUTIVE REPRESENTATIVE

Name: _____________________________________________________

Title: _____________________________________________________

Telephone No.: ________________________________________________

Email Address: ________________________________________________

POINT OF CONTACT FOR PROPOSAL

Name: _____________________________________________________

Title: _____________________________________________________

Telephone No.: ________________________________________________

Email Address: ________________________________________________

POINT OF CONTACT FOR RECEIPT OF CONTRACT

Name: _____________________________________________________

Title: _____________________________________________________

Telephone No.: ________________________________________________

Email Address: ________________________________________________

2. TEXAS FAMILY CODE § 231.006(c)

Pursuant to Texas Family Code § 231.006(c), Respondents are required to include the name and social security number of each person with at least a 25 percent ownership interest of the business entity submitting the Proposal.

Respondents meeting the ownership criteria shall provide the names only with their Proposal.

Social security numbers will be required only from the Respondent selected for the award prior to the award of the resulting contract. Failure to provide the required information will result in disqualification of the Proposal and/or contract award.

Name: _____________________________________________________

Name: _____________________________________________________

Name: _____________________________________________________

Name: _____________________________________________________

3. TEXAS GOVERNMENT CODE § 669.003

Under the Texas Government Code § 669.003, a state agency may not enter into a contract with a Respondent that employs a former executive head of the state agency unless certain statutory conditions are met. By signing the acknowledgment below, the Respondent certifies that it is in compliance with § 669.003. If §669.003 applies, the Respondent shall complete the following information in order for its Proposal to be evaluated:

Name of Former Executive: _________________________________________

Name of State Agency: _____________________________________________

Date of Separation from State Agency: __________________________________

Date of Employment with Respondent: _________________________________

4. PREFERENCES

See Texas Comptroller of Public Accounts, Statewide Procurement Division, State of Texas Procurement and Contract Management Guide, APPENDIX 21 (Version 1.3).

Identify the preferences for which you qualify:

☐ Preference for Products of Persons with Mental Retardation or Physical Disabilities. Tex. Gov’t Code § 2155.441.

☐ Preference for Energy Efficient Products. Tex. Gov’t Code § 2155.442.

☐ Preference for Rubberized Asphalt Paving. Tex. Gov’t Code § 2155.443.

☐ Preference to Texas and United States Products and Texas Services. Tex. Gov’t Code § 2155.444.

☐ Preference Under Service Contracts. Tex. Gov’t Code § 2155.4441.

☐ Preference for Recycled, Remanufactured, or Environmentally Sensitive Products. Tex. Gov’t Code § 2155.445.

☐ Purchase of Recycled Oil. Tex. Gov’t Code § 2155.447.

☐ Preference to Products and Services from Economically Depressed or Blighted Area. Tex.

Gov’t Code § 2155.449.

☐ Preference for Products of Facilities on Formerly Contaminated Property. Tex. Gov’t Code § 2155.450.

☐ Vendors that Meet or Exceed Air Quality Standards. Tex. Gov’t Code § 2155.451.

☐ Preference for Contractors Providing Foods of Higher Nutritional Value. Tex. Gov’t Code § 2155.452.

5. EXCEPTIONS TO TERMS AND CONDITIONS

☐ No exceptions.

☐ Yes, please provide list of exceptions below

Section Exception

6. RESPONDENT ACKNOWLEDGMENT

Respondent hereby acknowledges that it can meet all requirements as stated and also acknowledges the receipt, review, and acceptance of the Request for Proposals identified in its proposal. Any exceptions to the statement of work, terms, requirements, and conditions have been explicitly set forth in the Respondent’s proposal. Failure to sign and submit this form with its proposal may disqualify Respondent’s proposal.

7. SIGNATURE

By signing this Execution of Proposal, Respondent certifies that the responses are true and accurate and that if a Texas address is shown as the address of the Respondent, the Respondent qualifies as a Texas Resident Bidder as defined in Texas Government § 2252.001(4).

Signature: ____________________________________________________

Printed Name: _________________________________________________

Date: __________________________