APPENDIX A

RECEIPT OF ACKNOWLEDGEMENTS

(THIS FORM SHOULD BE INCLUDED IN PROPOSAL PACKAGE OTHERWISE BID MAY

BE CONSIDERED NON-RESPONSIVE)

I AM IN RECEIPT OF AND ACKNOWLEDGE ALL ADDENDA ISSUED IN REFERENCE TO

THE ABOVE LISTED BID.

YES__________

NO__________

NOT APPLICABLE_________

I ACKNOWLEDGE THE REVIEW OF ALL PLANS AND DRAWINGS RELATED TO THE

ABOVE-LISTED BID.

NO___________

NOT APPLICABLE__________

I ACKNOWLEDGE ALL REFERENCED EXCLUSIONS PERTANING TO THE ABOVE

LISTED BID.

NO___________

NOT APPLICABLE__________

Submitted by and Title

Company Name

Date

APPENDIX B

NOTICE OF PROPRIETARY INFORMATION FORM

Confidentiality References Protection in accordance with the Code of Virginia, Section 2.2-4342

INSTRUCTIONS: Identify the data or other materials to be protected and state the reasons by using the codes listed below. Indicate the specific words, figures or paragraphs that constitute trade secrets or proprietary materials. The classification of an entire bid or proposal document, line-item prices and/or total bid or proposal prices as proprietary or trade secret is not acceptable and will result in rejection of the bid or proposal.

A. This page contains information relating to “Trade Secrets” and •Proprietary Information" including processes, operations. style of work or apparatus. Identify confidential statistical data.

Amount or source of any income... of any person or partnership. ·'Sec Virginia Public Procurement

Act. Section 2.2-4342. Unauthorized disclosure of such information would violate the Trade Secrets Act

U.S.C. 1905.

B. This page contains proprietary information including confidential. commercial or financial information. which was provided to the Government on a voluntary basis and is of the type that would not customarily release to the public. Sec Virginia Public Procurement Act, Section 2.2-4342, 5 U.S.C. 552 (b)(4); 12 C.F.R. 309.5(c) (4).

C. This page contains proprietary information including confidential, commercial or financial information.

The disclosure of such information would cause substantial harm to competitive position and impair the Government's ability to obtain necessary information from contractors in the future.

5 U.S.C. See Virginia Public Procurement Act. Section 2.2-4342, 552 (b) (4); 12

C.F.R. 309.5(c)(4)

SECTION TITLE

PAGE NUMBER

REASON(S) FOR WITHOLDING FROM

DISCLOSURE

APPENDIX C

VENDOR DATA SHEET

Note: The following information is required as part of your response to this solicitation. Failure to complete and provide this sheet may result in finding your bid nonresponsive.

1. Qualification: The Bidder must have the capability and capacity in all respects to fully satisfy the contractual requirements.

2. Vendor’s Primary Contact:

Name: __________________Phone: _______________Email Address: _________________________

Years in Business: Indicate the length of time you have been in business providing this type of good or service: Years: ______ Months: ______

3. Vendor Information:

FIN or FEI Number: _______________________ If Company Corporation or Partnership Social

Security Number _______________ If Individual

4. Indicate below a listing of at least three (3) current or recent accounts, either commercial, or governmental that your company is servicing, has serviced or has provided similar goods. Include the length of service and the name, address and telephone number of the point of contact. (Failure to include references may be cause for rejection of the proposal as non-responsive).

A. Company: ______________________ Contact: ______________________

Phone: ___________________ Email: _____________________________

Project Dates of Service: __________________to_____________________

B. Company: ______________________ Contact: ______________________

C. Company: ______________________ Contact: ______________________

I certify the accuracy of this information.

Signed: ___________________________ Title: ______________________

Date: ___________________________

ATTACHMENT A

CONFLICT-OF-INTEREST STATEMENT

I. Ensure that the solicitation is thoroughly read and completed. Complete, sign and return the information requested below with your bid. FAILURE TO FURNISH THIS DATA MAY

RESULT IN DECLARING YOUR BID NON-RESPONSIVE.

NAME:

ADDRESS:

CITY/STATE:

TELEPHONE NUMBER:

RELATIONSHIP WITH THE COMMONWEALTH OF VIRGINIA:

IS ANY MEMBER OF THE FIRM AN EMPLOYEE OF THE COMMONWEALTH OF VIRGINIA

WHO HAS A PERSONAL INTEREST IN THIS CONTRACT PURSUANT TO THE

CODE OF VIRGINIA. SECTION 2.1-639.1 - 639.24.

( ) YES ( ) NO

IF YES, EXPLAIN:

SIGNATURE OF OFFEROR DATE

ATTACHMENT B

STATE CORPORATION COMMISSION FORM

Virginia State Corporation Commission (SCC) registration information. The bidder:

is a corporation or other business entity with the following SCC identification number: ___________

-OR-

is not a corporation, limited liability company, limited partnership, registered limited liability partnership, or business trust -OR-is an out-of-state business entity that does not regularly and continuously maintain as part of its ordinary and customary business any employees, agents, offices, facilities, or inventories in Virginia

(not counting any employees or agents in Virginia who merely solicit orders that require acceptance outside Virginia before they become contracts, and not counting any incidental presence of the bidder in

Virginia that is needed in order to assemble, maintain, and repair goods in accordance with the contracts by which such goods were sold and shipped into Virginia from bidder’s out-of-state location) -OR-is an out-of-state business entity that is including with this bid an opinion of legal counsel which accurately and completely discloses the undersigned bidder’s current contacts with Virginia and describes why those contacts do not constitute the transaction of business in Virginia within the meaning of § 13.1-757 or other similar provisions in Titles 13.1 or 50 of the Code of Virginia.

**NOTE** >> Check the following box if you have not completed any of the foregoing options but currently have pending before the SCC an application for authority to transact business in the

Commonwealth of Virginia and wish to be considered for a waiver to allow you to submit the SCC identification number after the due date for bids (the Commonwealth reserves the right to determine in its sole discretion whether to allow such waiver):

ADDITIONAL FORMS

FORM A

M/WBE Business Subcontracting Plan

Solicitation No.: Project/Solicitation Name:

Contract Specialist: Solicitation Response Date:

It is the goal of the City that over 25% of its purchases be made from small businesses and 2% of its purchases be made from service-disabled veteran owned businesses. All potential offerors are required to return this document with their response.

Minority Business Enterprise (MBE): A for-profit business concern that is at least 51 percent owned and controlled by one or more minority person(s), or in the case of any publicly owned business, at least 51 percent of the stock of which is owned by one or more minorities; and whose management and daily business operations are controlled by one or more of the minority individuals who own it; and, is certified as such by the Virginia Department of Small Business and Supplier Diversity or other recognized certifying agency.

Small Business: "Small business” means a business which holds a certification as such by the

Virginia Department of Small Business and Supplier Diversity (DSBSD) on the due date for proposals. This shall also include DSBSD-certified women- owned and minority-owned businesses and businesses with DSBSD service-disabled veteran owned status when they also hold a DSBSD certification as a small business on the proposal due date.

Service-Disabled Veteran-owned Business: Service-disabled veteran owned business” means a business which holds certification as such by the Virginia Department of Small Business and

Supplier Diversity (DSBSD) on the due date for the proposals. This shall also include DSBSD-certified small, women- owned and minority-owned businesses.

Women Business Enterprise (WBE): A for-profit business concern that is at least 51 percent owned and controlled by one or more female person(s), or in the case of any publicly owned business, at least 51 percent of the stock of which is owned by one or more women; and whose management and daily business operations are controlled by one or more of the female individuals who own it; and, is certified as such by the Virginia Department of Small Business and

Supplier Diversity or other recognized certifying agency.

Offeror Name:

Preparer Name: Date: Click or tap to enter a date.

Who will be doing the work:

☐ I plan to use subcontractors (Complete Section 2)

☐ I plan to complete all Work (Complete

FORM B)

☐ Instructions

A. If you are certified as a S/SDV business, attach a copy of your S/SDV certification letter from

DSBSD.

B. If you are not certified as a S/SDV business, complete Section B of this form. For the offeror to receive credit for the S/SDV business subcontracting plan evaluation criteria, the offeror shall identify the portions of the contract that will be subcontracted to the S/SDV certified business for the initial contract period the initial contract period in Section B.

Offerors who are S/SDV businesses themselves will receive credit for the portion of work their firm performs and will be assigned remaining points based on proposed expenditures with certified S/SDV businesses for the initial contract period in relation to the offeror’s total price for the initial contract period.

Points will be assigned based on each offeror’s proposed subcontracting expenditures with certified S/SDV businesses for the initial contract period as indicated in Section B in relation to the offeror’s total price.

Section 2

If the “I plan to use subcontractors’ box is checked,” populate the requested information below, per subcontractor to show your firm's plans for utilization of S/SDV businesses in the performance of this contract for the initial contract period in relation to the offeror’s total price for the initial contract period. It is important to note that this proposed participation will be incorporated into the subsequent contract and will be a requirement of the contract. Failure to obtain the proposed participation dollar value or percentages may result in a breach of the contract

Section 2: Plans for Utilization of certified S/SDV Businesses for this Procurement (use additional sheets if necessary)

Subcontract #1

Company Name: SWaM Cert No:

FEIN: Certification Type S/SDV/M/WBE:

Contact Name: Contact Email:

Contact Address:

Contact Phone: Value % or $ (Initial Term):

Description of Work:

Subcontract #2

Subcontract #3

Subcontract #4

Company Name: SWaM Cert No:

FEIN: Certification Type S/SDV/M/WBE:

Contact Name: Contact Email:

Contact Address:

Contact Phone: Value % or $ (Initial Term):

Description of Work:

Company Name: SWaM Cert No:

FEIN: Certification Type S/SDV/M/WBE:

Contact Name: Contact Email:

Contact Address:

Contact Phone: Value % or $ (Initial Term):

Description of Work:

Company Name: SWaM Cert No:

FEIN: Certification Type S/SDV/M/WBE:

Contact Name: Contact Email:

Contact Address:

Contact Phone: Value % or $ (Initial Term):

Description of Work:

FORM B

STATEMENT OF INTENT TO WORK WITHOUT SUBCONTRACTING

Affidavit of:

I hereby certify that it is our intent to perform 100% of the work required for the Click or tap here to enter text. contract.

In making this certification, the Bidder states that the Bidder does not customarily subcontract elements of work for this type of project, and normally performs and will perform all elements of the work on this project with his/her own current workforce (full and part-time employees working directly for the company); and

The Bidder agrees to provide any additional information or documentation requested by the owner in support of the above statement.

The Bidder must provide documentation of the utilization of S/SDV firms or documentation of good faith efforts in the purchase of materials, supplies, or the leasing of equipment necessary to perform this scope of work.

The undersigned hereby certifies that he or she has read this certification and is authorized to bind the

Bidder to the commitments herein contained.

Date: Name of Authorized Officer:

Signature: Title:

Title:

State of , County of____________________

Subscribed and sworn to before me this day o f 20 My commission expires Notary Public

FORM C

Minority/Woman-Owned Business Good Faith Efforts Documentation

IF THE M/WBE GOAL ESTABLISHED FOR THIS CONTRACT HAS NOT BEEN MET OR THE CITY

REQUESTS THE SUBMITTAL THEREOF, THE BIDDER IS REQUIRED TO SUBMIT GOOD FAITH

EFFORTS AS OUTLINED IN THIS DOCUMENT.

THE BIDDER ACKNOWLEDGES AND CERTIFIES THAT THIS FORM ACCURATELY

REPRESENTS THE INFORMATION CONTAINED HEREIN.

Bidder: Date Submitted:

Name and Title: Signature:

NAMES OF CERTIFIED M/WBEs AND THE DATES ON WHICH THEY WERE SOLICITED TO BID

ON THIS PROJECT.

INCLUDE THE ITEMS OF WORK OFFERED AND THE DATES AND METHODS USED FOR

FOLLOWING UP INITIAL SOLICITATIONS TO DETERMINE WHETHER OR NOT SWAMs WERE

INTERESTED.

NOTE: ATTACH ADDITIONAL PAGES IF NECESSARY

Name of Vendor Certification Agency and No.

Date of Initial Solicitation

Item(s) of Work Follow-up

Dates and

Methods

ATTACH COPIES OF SOLICITATIONS, TELEPHONE RECORDS, FAX CONFIRMATIONS,

ELECTRONIC INFORMATION, ETC.

M/WBE GOOD FAITH EFFORTS DOCUMENTATION

IF THE M/WBE GOAL ESTABLISHED FOR THIS CONTRACT HAS NOT BEEN MET OR THE

CITY REQUESTS THE SUBMITTAL THEREOF, THE BIDDER IS REQUIRED TO SUBMIT

GOOD FAITH EFFORTS AS OUTLINED IN THIS DOCUMENT.

THE BIDDER ACKNOWLEDGES AND CERTIFIES THAT THIS FORM ACCURATELY

REPRESENTS THE INFORMATION CONTAINED HEREIN.

OFFEROR: TITLE:

SIGNATURE:

ADDITIONAL DATA TO SUPPORT DEMONSTRATION OF GOOD FAITH EFFORTS

ADDITIONAL DATA TO SUPPORT DEMONSTRATION OF GOOD FAITH

EFFORTS