EXHIBIT A1 - SCWA Disclosure Form.docx
DOCX document 40 KB Posted
- Solicitation number
- 1669A
- Issued by
- Suffolk County, New York
About this file
The document is an Exhibit A1 Disclosure Form from the Suffolk County Water Authority (SCWA), designed to capture detailed vendor information for a competitive bidding process. The form requires potential vendors to provide comprehensive organizational details, including business type, principal information, and shareholder composition, specifically highlighting any individuals who are also SCWA officers or employees. The disclosure form is part of the RFP No. 1669A for Radio Frequency (RF) Consulting Services, with a mandatory pre-bid conference scheduled for November 19, 2025, at 10:00 a.m. in Bayshore, NY, and proposal submissions due electronically by December 16, 2025, at 11:00 a.m. EST via www.BidNetDirect.com/new-york.
The form emphasizes transparency and potential conflict of interest disclosure, with a specific provision that failure to file a verified public disclosure statement constitutes a material breach of contract. While no specific budget is outlined in this document, the related contract opportunity suggests a significant technology investment for developing a new wireless communications network for SCWA's SCADA system. Disadvantaged Business Enterprises (DBEs) are encouraged to participate, and the procurement process is being directly managed by Jeffrey W. Szabo, SCWA's Chief Executive Officer. The project requires a consultant with specialized expertise in radio frequency design, wireless network engineering, and integration capabilities for municipal water infrastructure communication systems.
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Other files
| File | Type | Posted |
|---|---|---|
| Appendix A - Pump Stations.pdf | ||
| EXHIBIT E - 1669A.docx | DOCX document | |
| RFP 1669A - Appendix A - Pump Station and Tank Database R1.xlsx | XLSX spreadsheet | |
| Request for Proposal.pdf | ||
| Subcontractor Insurance Agreement (If Applicable).docx | DOCX document | |
| EXHIBIT B - Affirmation of Understanding and Compliance.docx | DOCX document | |
| EXHIBIT C - Insurance Carriers or Agents Acknowledgment Form.docx | DOCX document | |
| EXHIBIT D - Contact Information.docx | DOCX document | |
| Exhibit F - Proposer Acknowledgment Form.docx | DOCX document | |
| RFP 1669 - Appendix B - Combined Drawings.pdf | ||
| RFP 1669A - Appendix C - FCC Licenses.xlsx | XLSX spreadsheet | |
| Appendix A - Tanks and Towers.pdf | ||
| Exhibit A - Form of Offerer Disclosure.docx | DOCX document |
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Text version
EXHIBIT A1
Suffolk County Water Authority Disclosure Form
1. Vendor’s Name ______________________________________________________________ Address_______________________________________________________________________ City and State ________________________________________________ Zip ______________
2. Type of Business: _____Corporation _____Partnership _____Sole Proprietorship _____Other__
3. Table of Organization. List names and addresses of all principals; that is, all individuals serving on the Board of Directors or comparable body, names and addresses of all partners, members, and names and addresses of all corporate officers. Conspicuously identify any person in this table of organization who is also an officer or an employee of Suffolk County Water Authority. (Attach additional sheet if necessary.)
4. List all names and addresses of those individual shareholders and members holding more than five percent (5%) interest in the Contractor/vendor. Conspicuously identify any shareholder who is also an officer or an employee of Suffolk County Water Authority. (Attach additional sheet if necessary).
5. Remedies. The failure to file a verified public disclosure statement shall constitute a material breach of Contract.
6. Verification. This section must be signed by an officer or principal of the Vendor authorized to sign for the company for the purpose of executing Contracts. The undersigned being sworn, affirms under the penalties of perjury, that he/she has read and understood the foregoing statements and that they are, to his/her own knowledge, true.
Dated: ______________ Signed: __________________________________________________ Printed Name of Signer: _________________________________________________________ Title of Signer: ________________________________________________________________ Name of Vendor: ______________________________________________________________ image1.jpeg
File details come from the government source that posted it. Updated .