Exhibit_A_-_Proposal_Forms.pdf

KENTON COUNTY AIRPORT BOARD CINCINNATI/NORTHERN KY INTERNATIONAL AIRPORT

CONVEYANCE EQUIPMENT

EXHIBIT A

PROPOSAL DOCUMENTS

Table of Contents

PROPOSAL

PROPOSAL FORM

EEO CERTIFICATION

NONSEGREGATED FACILITIES CERTIFICATION

BIDDER’S QUALIFICATIONS

BID TAB

AFFIRMATIVE ACTION CERTIFICATION

NON-DEBARMENT OR SUSPENSION CERTIFICATION

BUY AMERICAN CERTIFICATION – EQUIPMENT/BUILDING PROJECTS

DISCLOSURE OF LOBBYING ACTIVITIES CERTIFICATION

AFFIDAVIT REGARDING WORKER'S COMPENSATION

SAFETY EVALUATION AND PLANS

SAFETY EVALUATION FORM

CERTIFICATION OF OFFEROR/BIDDER REGARDING TAX DELINQUENCY AND FELONY CONVICTIONS 22

CERTIFICATION REGARDING DOMESTIC PREFERENCES FOR PROCUREMENTS

PROPOSAL

PROPOSAL FORM

TO: Owner Kenton County Airport Board Cincinnati/Northern Kentucky International Airport

Boone County, Kentucky P.O. Box 752000 Cincinnati, Ohio 45275-2000

FROM: Bidder

Address

City/State/Zip

DATE:

1. The undersigned bidder (“Bidder”) declares that having familiarized itself with the local conditions affecting the cost of the work, Contract Documents including the Notice to Bidders, Instructions to Bidders, Proposal and Bid Schedule, General Provisions, Special Provisions and the Specifications and Drawings and other related Documents prepared by the Kenton County Airport Board titled:

CINCINNATI/NORTHERN KENTUCKY INTERNATIONAL AIRPORT

dated September 21, 2026 together with any addenda to such Documents, proposes to furnish all materials and perform all work required in strict accordance with the provisions of the documents noted above for the consideration of prices quoted in 26-047-ITB Equip AIP titled the same as written above, which is incorporated by reference.

The Project delivers passenger conveyance equipment, including elevators, escalators, and moving walkways, as part of the Airport's terminal modernization program.

A. Included in the above improvements are all appurtenances required for complete and functional systems. It should be noted that other contractors may require access in the vicinity of the project site. Accordingly, cooperation between contractors and close coordination between all parties concerned will be required and is of utmost importance.

B. Bidder understands that the quantities shown in the "Bid Schedule" are approximate only, are intended principally to serve as a guide in evaluating proposals and are subject to either increase or decrease.

C. Bidder affirms that in making such bid, neither Bidder nor any company that Bidder may represent, nor anyone on behalf of Bidder, directly or indirectly, has entered into any combination, collusion, undertaking or agreement with any other bidder or bidders to maintain the prices of said work, or any compact to prevent any other bidder or bidders from bidding on said Contract or work and further affirms that such bid is made without regard or reference to any other bidder or proposer and without any agreement or understanding or combination either directly or indirectly with any other person or persons with reference to such bidding in any way or manner whatsoever.

D. Bidder shall enter into a Contract with the Owner within 10 days from the date on the

Notice of Award for the execution of the work described within the period of time allocated, and shall give Performance Bond and Payment Bond, with good and sufficient surety.

E. Contractor shall commence the work within 10 calendar days after the date of the Notice to Proceed. Contractor shall complete the work in accordance with the completion schedule set forth in the Special Provisions of these Specifications including amendments, if any. If Contractor fails to complete the work as provided in the completion schedule, Contractor expressly agrees that the Owner may deduct the stipulated sum of liquidated damages from the Contract price as provided in the Special Provisions for each day that any phase of work under this Contract remains uncompleted thereafter, and retain that sum for failure of the Contractor to complete this Contract on or before the expiration of the period shown in the completion schedule.

F. Contractor agrees that the Owner's damages caused by delay are capable of being established but would be difficult to measure accurately. Accordingly, the sums specified as liquidated damages in the Contract Documents are not a penalty, but represent the parties' estimate of the actual damages which the Owner would suffer per day if the work is not completed as scheduled.

G. The Owner reserves the right to waive any informality or irregularity in any bid or bid guaranty, to reject any and all bids, to award or refrain from awarding a contract for the work and to negotiate with an apparent qualified responsible low bidder to such extent as may be beneficial to the Owner. It is agreed THAT THIS BID MAY NOT BE WITHDRAWN

FOR A PERIOD OF 120 DAYS AFTER THE OPENING THEREOF.

H. Bidder has attached its Proposal Bond in in an amount equal to but not less than 5% of the aggregate amount of the bid, payable to the Kenton County Airport Board, as required in the Instructions to Bidders. Bidder agrees that in case Bidder fails to enter into the Contract and furnish the required Payment and Performance Bonds, with surety or sureties to be approved by Owner, and Insurance Certificates within 10 days after Notice of Award of the Contract to Bidder, the Owner may determine that Bidder has abandoned its rights and interest in such bid and that the Proposal Bond accompanying its bid has been forfeited. Otherwise, upon request by the Bidder the Proposal Bond will be returned to Bidder upon the execution of the Contract and acceptance of the Bonds and Insurance Certificates, or upon rejection of its bid.

I. Bidder affirms it has completed, signed and included in its submittal all required forms and pricing. A bid may be considered nonresponsive and rejected if it fails to include these fully executed statements or if Bidder fails to furnish required data. When a determination has been made to award the Contract to Contractor, Contractor shall furnish such other pertinent information regarding its own employment policies and practices as well as those of its proposed subcontractors as the FAA, the Owner, Secretary of Labor, the Labor Cabinet of the Commonwealth of Kentucky or the Office of Federal Contract Compliance (OFCC) may require.

J. Contractor shall furnish similar statements executed by each of its first-tier and second-tier subcontractors whose contracts equal Ten Thousand Dollars ($10,000.00) or more, and shall obtain similar compliance by such subcontractors before awarding subcontracts.

No subcontract may be awarded to any noncompliant subcontractor.

K. All work items are guaranteed for the warranty period stated in the bid from the date of

Final Acceptance. This is in addition to any third-party warranties.

L. Bidder affirms it has completed all of the unit prices on the Line Items tab on the online bidding system under Conveyance Equipment 26-047-ITB Equip AIP and agrees that where a discrepancy occurs the unit price governs when determining final costs or award of Contract.

M. Bidder agrees that the Contract amount will be decreased or increased where planned quantities shown on the drawings are decreased or increased, and that such increase or decrease shall be determined by use of the applicable unit price submitted in response to this ITB, except as provided for in Section 40-02 of the General Provisions.

N. Bidder affirms that wages not less than the minimum rates or wages, as predetermined for this project by the Department of Labor as provided in Section 7 of the Special Provisions of these Specifications, were used in the preparation of this proposal.

O. Bidder acknowledges the requirement to provide evidence of qualifications to conduct business as the project's contractor under the laws of the Commonwealth of Kentucky within five days following the Owner's issuance of a Notice of Award.

P. Bidder acknowledges that Contract Time will be based on the number of consecutive calendar days as stipulated in these Contract Documents beginning on the date the Notice-to-Proceed is issued by the Owner, with intermediate time(s) for selected phase(s) of work.

Q. The legal status of Bidder is:

1. A corporation duly incorporated under the laws of the state of ______________________________, and authorized to do business in the Commonwealth of Kentucky, for whom __________________________, bearing official title of ______________________, whose signature is affixed to this bid, is duly authorized to execute contracts.

The names, titles and business addresses of the President, Secretary and Treasurer are as follows:

President:

Secretary:

Treasurer:

If non-Kentucky corporation:

Date of qualification in Kentucky: _____________________________

Name and address of process agent in Kentucky:

2. A partnership, all of the members of which, with addresses are: (Designate general partners as such.)

If all partners are non-resident of Kentucky: (Designate name and address of agent for service of process located in Kentucky.)

3. An individual, whose signature is affixed to this Bid: (If non-resident of Kentucky, resident agent for the service of process must be designated below.)

The Bidder shall fill out the appropriate form (1., 2., or 3. above) and strike out the other two.

R. Bidder declares that the Bidder is the only person interested in this bid. This bid is made without any connection with any person making another bid for the same contract. Bidder did not, in any way, collude, conspire, or agree, directly or indirectly with any person, firm, corporation or other person in regard to the amount, terms, or conditions of this bid. No member of the Kenton County Airport Board (Board) or any person in the employ of the Board, is directly or indirectly interested in this bid, or in the supplies or work to which it relates or in any portion of the profits.

Dated and signed at _______________________________________________________, _______________ this _______ day of__________________, 20____.

NAME OF BIDDER:

BY:

TITLE:

BUSINESS ADDRESS: __________________________________________________________

WITNESS:

END OF SECTION

EEO CERTIFICATION

The Bidder certifies and agrees that all persons employed by such firm, its affiliates, subsidiaries, or holding companies are and will be treated equally by the firm without regard to or because of race, religion, ancestry, national origin, age, handicap, or sex, and in compliance with all anti-discrimination laws of the United States of America and the Commonwealth of Kentucky.

BIDDER'S CERTIFICATION

1. The Bidder has a written policy statement prohibiting discrimination in all phases of employment.

Answer "YES" or "NO" __________________

2. The Bidder periodically conducts a self-analysis or utilization analysis of its work force.

3. The Bidder has a system for determination if its employment practices are discriminatory against protected groups.

4. Where problem areas are identified in employment practices, the Bidder has a system for taking reasonable corrective action to include establishment of goals and timetables.

Answer "YES" or "NO” __________________

Name: Bidding Contractor ________________________________________________________

By __________________________________________ Date: _________

(SIGNATURE)

Name and Title _______________________________________________________

(PRINT OR TYPE)

Business Address _______________________________________________________

IRS Employer ID# _______________________________________________________

NONSEGREGATED FACILITIES CERTIFICATION

The Bidder certifies that it does not maintain or provide for its employees any segregated facilities at any of its establishments and that it does not permit its employees to perform their services at any location, under its control, where segregated facilities are maintained. The Bidder certifies further that it will not maintain or provide for its employees any segregated facilities at any of its establishments, and that it will not permit its employees to perform their services at any location, under its control, where segregated facilities are maintained. The Bidder agrees that a breach of this certification is a violation of the Equal Opportunity Clause in any resultant Contract. As used in this Certification, the term "segregated facilities" means any waiting rooms, work areas, restrooms and washrooms, restaurants and other eating areas, time clocks, locker rooms and other storage or entertainment areas, transportation, and housing facilities provided for employees which are segregated by explicit directive or are in fact segregated on the basis of race, color, religion, sex, or national origin, because of habit, local custom, or any other reason. The Bidder agrees that (except where it has obtained identical Certifications from proposed subcontractors for specific time periods) it will obtain identical Certifications from proposed subcontractors prior to the award of subcontracts exceeding $10,000 which are not exempt from the provisions of the Equal Opportunity Clause, and that it will retain such Certifications in its files.

Per 41 CFR 60-1.8, Contractors receiving federally-assisted construction contract awards, and Contractors receiving subcontract awards, exceeding $10,000 which are not exempt from the provisions of the Equal Opportunity Clause will be required to provide for the forwarding of the below notice to prospective contractors for supplies and construction contracts where the subcontracts exceed $10,000 and are not exempt from the provisions of the Equal Opportunity Clause.

CERTIFICATION TO BE SUBMITTED BY FEDERALLY ASSISTED CONSTRUCTION CONTRACTORS AND THEIR SUBCONTRACTORS (APPLICABLE TO FEDERALLY ASSISTED CONSTRUCTION CONTRACTS AND RELATED

SUBCONTRACTS EXCEEDING $10,000 WHICH ARE NOT EXEMPT FROM THE EQUAL OPPORTUNITY

CLAUSE).

CERTIFICATION

The information above is true and complete to the best of my knowledge and belief. (Note: The penalty for making false statements in offers is prescribed in 18 U.S.C. 1001).

Name: Bidding contractor __________________________________________________________

By _________________________________________Date: _____________

(SIGNATURE)

Name and Title __________________________________________________________

(PRINT OR TYPE)

Business Address __________________________________________________________

IRS Employer ID# __________________________________________________________

BIDDER’S QUALIFICATIONS

Each bidder shall furnish the following completed and signed statements on "evidence of competency" and "evidence of financial responsibility" with its bid in accordance with General Provision 20-02. In addition, the Owner reserves the right to conduct such additional investigation into the competency and responsibility of the bidders (or any particular bidder) as the Owner may deem necessary.

1. Name of Bidder: _____________________________________________________

2. Business address: ____________________________________________________

3. Telephone number: ___________________________________________________

4. When organized: _____________________________________________________

5. Where incorporated: __________________________________________________

6. How many years have you been engaged in the contracting business under the present firm name?

7. What is the type of construction work in which you are principally engaged?

8. On separate sheet, list major contracts in past 10 years.

9. On separate sheet, list equipment and plant available for this project.

10. Enclose evidence of financial responsibility per General Provisions Section 20-02.

11. Credit available for this Contract $________________________

12. On a separate sheet, list all projects presently under Contract by name, gross amount, and percent complete.

13. Have you ever refused to sign a Contract at your original bid? _________________

14. Have you ever been declared in default on a Contract? ______________________

15. Total amount of bonding capacity $ _______________________________________

16. Total bonding capacity available for the project $ ____________________________

17. Remarks: ___________________________________________________________________

(The above statements must be subscribed and sworn to before a Notary Public.)

Date: _______________________________________

Firm Name: __________________________________

By: _________________________________________ (Signature)

Title: ________________________________________

STATE OF ___________________________________

COUNTY OF _________________________________

Subscribed and sworn to before me, a Notary Public, in and for the County and State aforesaid by

______________________________ duly authorized so to sign this _____ day of __________________, 20____.

Notary Public

My Commission Expires: _____________________________

BID TAB

** For reference only – pricing must be submitted through the online bidding system **

Line Item Description Quantity Unit of Measure 1 Escalator 8 ea

Hydraulic Passenger Elevators 5 ea

Traction Passenger Elevators 2 ea

Moving Walkways - AGT Tunnel 4 ea

Alternate 1

Installation of escalators 8 ea

Installation of hydraulic passenger elevators 5 ea

Installation of traction passenger elevators 2 ea

Installation of moving walkways 4 ea

Alternate 2

Monthly off-site storage fees 1 mo

Alternate 3 10 Mobilization 1 ea

Preventative and corrective Maintenance, Year 1 1 yr

Preventative and corrective Maintenance, Year 2 1 yr

Preventative and corrective Maintenance, Year 3 1 yr

Preventative and corrective Maintenance, Year 4 1 yr

Preventative and corrective Maintenance, Year 5 1 yr

AFFIRMATIVE ACTION CERTIFICATION

The Bidder HAS / HAS NOT (strike out inappropriate term) participated in a previous contract subject to the Equal Opportunity Clause prescribed by Executive Order 10925, or Executive Order 11246, or Executive Order 11114.

The Bidder HAS / HAS NOT (strike out the inappropriate term) submitted all compliance reports in connection with any such contract due under the applicable filing requirements; and that representations indicating submission of required compliance reports signed by proposed subcontractors will be obtained prior to award of subcontracts.

If the Bidder has participated in a previous contract subject to the Equal Opportunity Clause and has not submitted compliance reports due under applicable filing requirements, the Bidder shall submit a compliance report on Standard Form 100, "Employee Information Report" prior to the award of the Contract.

Name: Bidding Contractor _______________________________________________________

By _____________________________________Date:_______________

(SIGNATURE)

Name and Title ________________________________________________________

NON-DEBARMENT OR SUSPENSION CERTIFICATION

In accordance with the CODE OF FEDERAL REGULATIONS, Part 49, CFR Section 29.510, the Bidder, being duly sworn (or under penalty of perjury under the laws of the United States), certifies to best of his/her knowledge and belief, that its principals:

1. are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any federal department or agency;

2. have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of record, making false statements, or receiving stolen property;

3. are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (federal, state, or local) with commission of any of the offenses enumerated in the above paragraph of this certification; and

4. have not within a three-year period preceding this proposal had one or more public transactions (federal, state, or local) terminated for cause or default.

Where the Bidder is unable to certify to any of the statements in this certification, such Bidder shall list exceptions below. Exceptions will not necessarily result in denial of award, but will be considered in determining contractor responsibility. For any exception noted, indicate below to whom it applies, the initiating agency, and the dates of the action. Providing false information may result in criminal prosecution or administrative sanction. If an exception is noted, the Bidder must contact the Sponsor to discuss the exception prior to award of the Contract.

The Bidder certifies under penalty of perjury under the laws of the Commonwealth of Kentucky that the foregoing is correct and true.

Name: Bidding contractor ___________________________________________________

By _________________________________Date:_______________

(SIGNATURE)

Name and Title ____________________________________________________

Subscribed and sworn before me this date: Month _________ Day ______ Year __________

Notary Public's signature: ____________________________________________________

Commission expires: _________________________________________________________

BUY AMERICAN CERTIFICATION –

EQUIPMENT/BUILDING PROJECTS

The contractor shall comply with 49 USC § 50101, which provides that Federal funds may not be obligated unless all steel and manufactured goods used in AIP-funded projects are produced in the United States, unless the FAA has issued a waiver for the product; the product is listed as an Excepted Article, Material Or Supply in Federal Acquisition Regulation subpart 25.108; or is included in the FAA Nationwide Buy American Waivers Issued list.

As a matter of bid responsiveness, the bidder or offeror must complete, sign, date, and submit this certification statement with their proposal. The bidder or offeror must indicate how they intend to comply with 49 USC § 50101, and other Made in America Laws, U.S. statutes, guidance, and FAA policies by selecting one on the following certification statements. These statements are mutually exclusive. Bidder must select one or the other (not both) by inserting a checkmark () or the letter “X”.

Bidder or offeror hereby certifies that it will comply with 49 USC § 50101, BABA and other related U.S. statutes, guidance, and policies of the FAA by:

a) Only installing steel and manufactured products produced in the United States;

b) Only installing construction materials defined as: an article, material, or supply – other than an item of primarily iron or steel; a manufactured product; cement and cementitious materials; aggregates such as stone, sand, or gravel; or aggregate binding agents or additives that are or consist primarily of non-ferrous metals;

plastic and polymer-based products (including polyvinylchloride, composite building materials, and polymers used in fiber optic cables); glass (including optic glass); lumber or drywall that have been manufactured in the United States.

c) Installing manufactured products for which the Federal Aviation Administration (FAA) has issued a waiver as indicated by inclusion on the current FAA Nationwide Buy American Waivers Issued listing; or

d) Installing products listed as an Excepted Article, Material or Supply in Federal Acquisition Regulation Subpart 25.108.

By selecting this certification statement, the bidder or offeror agrees:

a) To provide to the Airport Sponsor or FAA evidence that documents the source and origin of the steel and manufactured product.

b) To faithfully comply with providing U.S. domestic product.

c) To furnish U.S. domestic product for any waiver request that the FAA rejects.

d) To refrain from seeking a waiver request after establishment of the contract, unless extenuating circumstances emerge that the FAA determines justified.

The bidder or offeror hereby certifies it cannot comply with the 100 percent Buy American

Preferences of 49 USC § 50101(a) but may qualify for a Type 3 waiver under 49 USC §

50101(b). By selecting this certification statement, the apparent bidder or offeror with the apparent low bid agrees:

a) To submit to the Airport Sponsor or FAA within 15 calendar days of being selected as the responsive bidder, a formal waiver request and required documentation that supports the type of waiver being requested.

b) That failure to submit the required documentation within the specified timeframe is cause for a non-responsive determination that may result in rejection of the proposal.

c) To faithfully comply with providing U.S. domestic products at or above the approved U.S. domestic content percentage as approved by the FAA.

d) To refrain from seeking a waiver request after establishment of the contract, unless extenuating circumstances emerge that the FAA determines justified.

Required Documentation

Type 2 Waiver (Nonavailability) - The iron, steel, manufactured goods or construction materials are not available in sufficient quantity or quality in the United States. The required documentation for the Nonavailability waiver is:

a) Completed Content Percentage Worksheet and Final Assembly Questionnaire

b) Record of thorough market research, consideration where appropriate of qualifying alternate items, products, or materials including;

c) A description of the market research activities and methods used to identify domestically manufactured items capable of satisfying the requirement, including the timing of the research and conclusions reached on the availability of sources.

Type 3 Waiver – The cost of the item components and subcomponents produced in the United States is more that 60 percent of the cost of all components and subcomponents of the “item”.

The required documentation for a Type 3 waiver is:

a) Completed Content Percentage Worksheet and Final Assembly Questionnaire including;

b) Listing of all product components and subcomponents that are not comprised of 100 percent U.S. domestic content (Excludes products listed on the FAA Nationwide Buy American Waivers Issued listing and products excluded by Federal Acquisition Regulation Subpart 25.108 (products of unknown origin must be considered as non-domestic products in their entirety).

c) Cost of non-domestic components and subcomponents, excluding labor costs associated with final assembly at place of manufacture.

d) Percentage of non-domestic component and subcomponent cost as compared to total “item” component and subcomponent costs, excluding labor costs associated with final assembly at place of manufacture.

Type 4 Waiver (Unreasonable Costs) - Applying this provision for iron, steel, manufactured goods or construction materials, would increase the cost of the overall project by more than 25 percent.

The required documentation for this waiver is:

a) Completed Content Percentage Worksheet and Final Assembly Questionnaire from

b) At minimum two comparable equal bidders and/or offerors;

c) Receipt or record that demonstrates that supplier scouting called for in Executive

Order 14005, indicates that no domestic source exists for the project and/or component;

d) Completed waiver applications for each comparable bid and/or offer.

False Statements: Per 49 USC § 47126, this certification concerns a matter within the jurisdiction of the Federal Aviation Administration and the making of a false, fictitious, or fraudulent certification may render the maker subject to prosecution under Title 18, United States Code.

Date Signature

Company Name Title

DISCLOSURE OF LOBBYING ACTIVITIES CERTIFICATION

Certification for Federal-Aid Construction Services. In accordance with Public Law 101-1210, Section 319, by signing and submitting this bid, the Bidder certifies to the best of Bidder’s knowledge and belief:

1. that no federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any federal agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative agreement; and

2. that if any funds other than federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence and officer or employee of any federal agency, a Member of Congress, and officer or employee of Congress, or an employee of a Member of Congress in connection with this federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form -LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions.

This certification is a material representation of fact upon which reliance will be placed when a transaction is made or entered into. Submission of this Certification is a prerequisite for making or entering into a transaction imposed by Section 1352, Title 31, United States Code. Any person who fails to file the required Certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

The Bidder also agrees by submitting its bid that Bidder shall require the language of this Certification be included in all lower tier subcontracts, which exceed $100,000 and all subrecipients shall certify and disclose accordingly.

The Bidder certifies under penalty of perjury under the laws of the Commonwealth of Kentucky that the foregoing is correct and true.

Name: Bidding contractor ________________________________________________________

By __________________________________________Date:__________

(SIGNATURE)

Name and Title ________________________________________________________

(PRINT OR TYPE)

Subscribed and sworn before me this date: Month _____________________ Day ______ Year _____

Notary Public's signature: ______________________________________________

Commission expires: ______________________________________________

AFFIDAVIT REGARDING WORKER'S COMPENSATION

The undersigned Contractor, being awarded a Contract by the Kenton County Airport Board, operator of the Cincinnati/Northern Kentucky International Airport, identified as:

________________________________ hereby assures that all Contractors and subcontractors employed, or that will be employed, under the provisions of the foregoing identified contract shall be in compliance with Kentucky requirements for Worker's Compensation Insurance according to KRS Chapter 342 and unemployment insurance according to KRS Chapter 341.

DATED this day of , 20____.

Signature: ___________________________________________________

Name and Title (Printed):

STATE OF

COUNTY OF

Subscribed and sworn to before me, a Notary Public, by ________ , on behalf of the foregoing identified Contractor this day of ____ 20 .

Notary Public

My Jurisdiction is:

My Commission Expires:

SAFETY EVALUATION AND PLANS

1.1 It is the goal of the Board to maintain a safe working environment for contractors, subcontractors and Airport personnel. All bidders must provide the following safety information for the bidder and all subcontractors for the three previous calendar years on the attached Safety Evaluation Form:

1. Documented DART Rate;

a. Desired DART Rate equal to or less than the BLS industry average

2. NCCI Workers’ Compensation Experience Modification Rate (EMR):

a. Desired EMR of 1.0 or less

3. Documented Recordable Incidence Rate;

a. Desired Incident Rate equal to or less than the BLS industry average

b. The rates for the “Construction” Industry Sector on the Bureau of Labor

Statistics most recent Table 7 - Incidence rates of nonfatal occupational injuries and illnesses by major private industry sector and selected case types will be used for comparison with industry standard. Table 7 may be found at http://www.bls.gov/news.release/osh.t07.htm

c. Information on calculating Incident Rates can be found at http://data.bls.gov/iirc/

4. Completed and signed OSHA 300 logs & OSHA 300A forms; and,

5. Any serious or willful KYOSHA, Federal OSHA or any other state OSHA plan violations.

1.2 At or before the preconstruction meeting and prior to commencement of physical work on this project, the successful bidder shall provide:

1 A site-specific safety program for this project which includes the name of contractor’s safety manager for this project who will serve as the primary liaison to the Board for safety related issues, including all safety issues relating to subcontractors;

2 Certification that all contractor and subcontractor personnel on the project have been trained on the site-specific safety program;

3 Completed and signed Contractor Safety Survey (form provided by Owner); and, 4 A description of Contractor’s and all subcontractors’ alcohol and drug free workplace plans, which at least includes pre-employment and post-accident drug and alcohol testing, and certification that all personnel working on the project are in compliance with these plans.

http://www.bls.gov/news.release/osh.t07.htm http://data.bls.gov/iirc/

CONVEYANC EQUIPMENT

*Bidder to make photocopies of this sheet if additional room is required. END OF SECTION

SAFETY EVALUATION FORM

Bidders must provide the following information for its company and all subcontractors which will be doing work on this project for evaluation by the Owner.

See Specifications for further details.

COMPANY NAME Discipline Documented recordable Incident Rate

NCCI WORKER’S

COMPENSATION

EXPERIENCE

MODIFICATION

FACTOR(EMR)

Serious or Willful KOSHA or Other State Plan

VIOLATIONS

If greater than “0" provide written details.

DOCUMENTED DART

RATE

(Last three calendar years)

2023 2024 2025 2023 2024 2025 2023 2024 2025 2023 2024 2025

CERTIFICATION OF OFFEROR/BIDDER REGARDING TAX DELINQUENCY AND FELONY

CONVICTIONS

The applicant must complete the following two certification statements. The applicant must indicate its current status as it relates to tax delinquency and felony conviction by inserting a checkmark () in the space following the applicable response. The applicant agrees that, if awarded a contract resulting from this solicitation, it will incorporate this provision for certification in all lower tier subcontracts.

Certifications

1) The applicant represents that it is (____) is not (____) a corporation that has any unpaid Federal tax liability that has been assessed, for which all judicial and administrative remedies have been exhausted or have lapsed, and that is not being paid in a timely manner pursuant to an agreement with the authority responsible for collecting the tax liability.

2) The applicant represents that it is (____) is not (____) a corporation that was convicted of a criminal violation under any Federal law within the preceding 24 months.

Note

If an applicant responds in the affirmative to either of the above representations, the applicant is ineligible to receive an award unless the sponsor has received notification from the agency suspension and debarment official (SDO) that the SDO has considered suspension or debarment and determined that further action is not required to protect the Government’s interests. The applicant therefore must provide information to the Owner about its tax liability or conviction, who will then notify the FAA Airports District Office, which will then notify the agency’s SDO to facilitate completion of the required considerations before award decisions are made.

Term Definitions

Felony conviction: Felony conviction means a conviction within the preceding twenty-four (24) months of a felony criminal violation under any Federal law and includes conviction of an offense defined in a section of the U.S. code that specifically classifies the offense as a felony and conviction of an offense that is classified as a felony under 18 U.S.C. § 3559.

Tax Delinquency: A tax delinquency is any unpaid Federal tax liability that has been assessed, for which all judicial and administrative remedies have been exhausted, or have lapsed, and that is not being paid in a timely manner pursuant to an agreement with the authority responsible for collecting the tax liability.

CERTIFICATION REGARDING DOMESTIC PREFERENCES FOR PROCUREMENTS

The Bidder or Offeror certifies by signing and submitting this bid or proposal that, to the greatest extent practicable, the Bidder or Offeror has provided a preference for the purchase, acquisition, or use of goods, products, or materials produced in the United States (including, but not limited to, iron, aluminum, steel, cement, and other manufactured products) in compliance with 2 CFR § 200.322.