EXHIBITS_A-D_&_F-J_Fillable.pdf

EXHIBIT A

PROPOSER'S CERTIFICATION

I have carefully examined the Solicitation and any other documents accompanying or made a part of this Solicitation.

I hereby propose to furnish the goods or services specified in the Solicitation at the prices or rates quoted in my Proposal. I agree that my Proposal will remain firm for a period of up to one hundred eighty (180) days in order to allow the College adequate time to evaluate the Proposals.

I agree to abide by all conditions of this Proposal and understand that a background investigation may be conducted by the College prior to award.

I certify that all information contained in this Proposal is truthful to the best of my knowledge and belief. I further certify that I am duly authorized to submit this Proposal on behalf of the Proposer as its act and deed and that the Proposer is ready, willing, and able to perform if awarded the Contract.

I certify, under oath, that this Proposal is made without prior understanding, agreement, connection, discussion, or collusion with any other person, Firm or Corporation submitting a Proposal for the same product or service and is all respects fair and without fraud. I further certify that no officer, employee, or agent of the College or of any other Proposer has a financial interest in this Proposal. I further certify that the undersigned executed this Proposer's Certification with full knowledge and understanding of the matters therein contained and was duly authorized to do so.

Name of Business: ______________________________________________________________________

Name Printed: _____________________________ Title: ___________________________________

Signature: _____________________________________________________________________________

Mailing Address, or if different from your principal place of business:

Address: _________________________________ City, State, Zip: ____________________________

Telephone Number: ____________________ Email address: _________________________________

Duns Number: _________________________ Company Tax ID #: ____________________________ Note: (The College only requires Company Tax Id numbers. The College is not requesting individual social security numbers.)

Personally appeared before me, the undersigned authority, who after first being sworn to me, affixed his/her signature in the space provided above on this _______ day of_____________, 20 ________ by

___ personally known to me or ___ produced identification _____________________________________

Signature of Notary Public

State of County of My commission expires:

EXHIBITS PAGE 1

EXHIBIT B

PROPOSER INFORMATION AND SIGNATURE FORM

Company Name (as reported to the IRS):

Purchasing Address: City, State, Zip:

Remit to Address: City, State, Zip:

Phone #: Web page address:

Parent Company Address (if applicable): City, State, Zip:

Contact Person:

(for project notification) Title:

Email Address: Phone #:

Federal Employer Tax Identification #:

Company Ownership (Check all that apply):

Company is at least 51% owned, controlled, and actively manage by

____ Minority Person ____ Woman/Women ____ Disabled Vet ____LDB Minority Ownership (Check all that apply):

Please attach your Minority Certification

____ African American ____Asian Indian American ____Asian Pacific American

____African American ____ Hispanic American ____ Other (specify)______________ Entity Providing Response:

____ Parent Company ____ Subsidiary ____ Division ____ Branch Office

Type of Company or Joint Venture:

____ Small Business ____ Government, City, State ____ Sole Proprietor

____ Partnership ____ Corporation ____ Joint Venture (JV) ____ Other (specify) _________________

Year Company/JV Established: Years of Experience in this Business:

Former Names:

List names under which the company or Joint Venture has done business [indicate N/A if not applicable)

Signature: Title:

Printed Name: Date:

All respondents certify by their signature, hereto, that they have read and understand the conditions and specifications of this solicitation and that they have the authority, capacity and capability to sign this document on behalf of the Company/Firm and will perform according to the conditions and specifications of this solicitation.

EXHIBITS PAGE 2

EXHIBIT C

CONFLICT OF INTEREST STATEMENT AND DISCLOSURE STATEMENT

CHECK ONE

____ The undersigned Company/Firm has no potential, real or apparent, conflict of interest due to any other clients, contracts, or property interest for this project.

OR

____ The undersigned Company/Firm, by EXHIBIT to this form, submits information which may be a potential conflict of interest due to other clients, contracts, or property interest for this project.

LITIGATION STATEMENT

Please answer the following questions Yes or No. If you answer yes to any of the questions, provide a full explanation below the question. (Attach additional pages if needed.)

1. Has your Company/Firm or any of its officers received a reprimand of any nature or been suspended by the Florida Department of Business and Professional Regulation (FDBR) or any other regulatory agency or professional association within the last ten (10) years. ____ Yes ____ No

2. Has your Firm or any member of your Firm been declared in default, terminated or removed from a contract or job related to the services your Firm provides in the regular course of business within the last ten (10) years? ____ Yes ____ No If yes, indicate company name, contact name, and telephone number, and reason for early cancellation/termination of contract.

3. Has your Firm had filed against it or filed any requests for equitable adjustment, contract claims, litigation and/or judgments during the past ten (10) years?

If you answered yes, include a summary and disposition of the case, the outcome, or status of suit and the monetary amounts involved.

I hereby certify that all statements made are true and I agree and understand that any misstatement or misrepresentation of falsification of facts shall be cause for disqualification of your proposal and forfeiture of rights for further consideration of this proposal process.

Company Name Name (Print)

Authorized Signature Title

Failure to provide the information requested, including documentation relating to potential conflicts of interest, or summary of past litigation and/or judgment may result in disqualification of your proposal.

EXHIBITS PAGE 3

EXHIBIT D

SWORN STATEMENT UNDER SECTION 287.133 (3) (a), FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES

THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICIAL

AUTHORIZED TO ADMINISTER OATHS.

This sworn statement is submitted to:

This sworn statement is submitted by:

Whose business address is:

and (if applicable) its Federal Employer Identification Number (FEIN) is:

(If entity has no FEIN, include the Social Security Number of the individual signing this sworn statement)

1. My name is and my relationship to the entity named above is:

2. I understand that a "public entity crime" as defined in Section 287.133(1)(g), Florida Statutes, means a violation of any state or federal law by a person with respect to and directly related to the transaction of business with any public entity or with an agency or political subdivision of any other state or of the United States, including, but not limited to, any bid or contract for goods or services to be provided to any public entity or an agency or political subdivision of any other state or of the United States and involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation. I understand that "convicted" or "conviction" as defined in Section

287.133 (1) (b), Florida Statutes, means a finding of guilt or a conviction of a public entity crime, with or without adjudication of guilt, in any federal or state trial court of record, relating to charges brought by indictment or information after July 1, 1989, as a result of a jury verdict, non-jury trial, or entry of a plea of guilty or nolo contendere.

3. I understand that an "affiliate" as defined in Section 287.133(1) (a), Florida Statutes, means:

(1) A predecessor or successor of a person convicted of a public entity crime; or (2) An entity under the control of any natural person who is active in the management of the entity and who has been convicted of a public entity crime. The term "affiliate" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in the management of an affiliate. The ownership by one person of shares constituting a controlling interest in another person, or a pooling of equipment or income among persons when not for fair market value under an arm's length agreement, shall be a prima facie case that one person controls another person. A person who knowingly enters into a joint venture with a person who has been convicted of a public entity crime in Florida during the preceding 36 months shall be considered an affiliate.

4. I understand that a "person" as defined in Section 287.133(1) (e), Florida Statutes, means any natural person or entity organized under the laws of any state or of the United States with the legal power to enter into a binding contract and which bids or applies to bid on contracts for the provision of goods or services let by a public entity, or which otherwise transacts or applies to transact business with a public entity. The term "person" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in management of an entity.

5. Based on information and belief, that statement which I have marked below is true in relation to the entity submitting this sworn statement. (Please indicate which statement applies.)

6. Neither the entity submitting this sworn statement, nor one or more of the officers, directors, EXHIBITS PAGE 4 executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, nor any affiliate of the entity, has been charged with and convicted of public entity crime subsequent to July 1, 1989.

7. There has been a proceeding concerning the conviction before a hearing officer of the State of Florida, Division of Administrative Hearings. The final order entered by the hearing officer did not place the person or affiliate on the convicted vendor list. [Please attach a copy of the Final Order.

8. The person or affiliate was placed on the convicted vendor list. There has been a subsequent proceeding before a hearing officer of the State of Florida, Division of Administrative Hearings. The final order entered by the hearing officer determined that it was in the public interest to remove the person or affiliate from the convicted vendor list. (Please attach a copy of the Final Order.)

The person or affiliate has not been placed on the convicted vendor list. (Please describe any action taken by or pending with the Department of General Services.)

Date: Signature:

Personally appeared before me, the undersigned authority, who after first being sworn to me, affixed his/her signature in the space provided above on this _ day of , 20 by

____ personally known to me or ____ produced identification _________________________

Signature of Notary Public

State of County of:

My commission expires:

EXHIBITS PAGE 5

EXHIBIT F

ADDENDUM RECEIPT VERIFICATION

The undersigned acknowledges receipt of the following addenda to this Solicitation (Give number and date of each):

Addendum No. _______________Dated ____________

Addendum No. _______________Dated ____________

Addendum No. _______________Dated ____________

Addendum No. _______________Dated ____________

Addendum No. _______________Dated ____________

____ By checking this box, the undersigned acknowledges they have read each of the questions and answers submitted via VendorLink.

FAILURE TO SUBMIT ACKNOWLEDGMENT OF ANY ADDENDUM THAT AFFECTS THE PROPOSAL

PRICES IS CONSIDERED A MAJOR IRREGULARITY AND WILL BE CAUSE FOR REJECTION OF THE

PROPOSAL.

Company Name __________________________________________

Authorized Signature ______________________________________________________

Name (Print or Type) ______________________________________________________

Title ______________________________________ Date: __________________________

EXHIBITS PAGE 8

EXHIBIT G

DRUG FREE WORKPLACE FORM

The undersigned contractor, in accordance with Florida Statute 287.087 hereby certifies that does:

NAME OF BUSINESS

1) Publish a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the workplace and specifying the actions that will be taken against employees for violations of such prohibition.

2) Inform employees about the dangers of drug abuse in the workplace, the business’s policy of maintaining a drug-free workplace, any available drug counseling, rehabilitation, employee assistance programs and the penalties that may be imposed upon employees for drug abuse violations.

3) Give each employee engaged in providing the commodities or contractual services that are under bid a copy of the statement specified in Paragraph 1.

4) In the statement specified in Paragraph 1, notify the employees that, as a condition of working on the commodities or contractual services that are under bid, the employee will abide by the terms of the statement and will notify the employer of any conviction of, or plea of guilty or nolo contendere to, any violation of Florida Statute 893 or of any controlled substance law of the United States or any state, for a violation occurring in the workplace no later than five (5) days after such conviction.

5) Impose a sanction on, or require the satisfactory participation in a drug abuse assistance or rehabilitation program if such is available in the employee’s community, by any employee who is so convicted.

6) Make a good faith effort to continue to maintain a drug-free workplace through implementation of Paragraphs 1 thru 5.

As the person authorized to sign this statement, I certify that this contractor complies fully with above requirements.

Signature

Print Name

Title

Date

EXHIBITS PAGE 9

EXHIBIT H

MINORITY BUSINESS ENTERPRISE/WOMAN BUSINESS ENTERPRISE CERTIFICATE

If your firm is greater than 51% owned and controlled by a woman or minority, please complete this certificate and include a copy with your submittal.

If firm is NOT claiming to be minority or woman business enterprise, submit form with signature and “NM” for Minority Type. (Notarization is NOT required)

I HEREBY DECLARE AND AFFIRM that I am the (Title) representative of the firm of (Company Name) minority business enterprise (Minority Type**) as defined by Valencia College in the specifications for (Project Name & Number) that I will provide information requested by COLLEGE to document this fact. The foregoing statements are true and correct and include all material necessary to identify and explain the operations of _______________ (Company Name) as well as the ownership thereof. Further, the undersigned does agree to provide COLLEGE current, complete and accurate information regarding actual work performed on the project, the payment therefor and any proposed changes in any of the arrangements hereinabove stated and to permit and audit an examination of the books, records and files of the above named company by authorized representative of COLLEGE. It is recognized and acknowledged that the statements herein are being given under oath and material misrepresentation will be grounds for terminating any contract which may be awarded in reliance hereon.

Termination is understood to forfeiture of payment for all work not performed at time of notification.

I DO SOLEMNLY DECLARE OR AFFIRM UNDER THE PENALTIES OF PERJURY THAT THE CONTENTS

OF THE FOREGOING DOCUMENTS ARE TRUE AND CORRECT, AND THAT I AM AUTHORIZED, ON

BEHALF OF THE ABOVE FIRM, TO MAKE THIS AFFIDAVIT.

(Signature of Company's Authorized Representative)

On this day of , 20 , before me, in the foregoing affidavit and acknowledged that he/she executed the same in the capacity therein stated and for the purpose therein contained.

In witness thereof, I hereunto set my hand and official seal.

(Notary Public)

My commission Expires:

State of County of City of

** Minority Type: # M1 Black American Man; M2 Hispanic American; M3 Asian American; M4 Native American (Eskimo & Aleutian);

M5 Native Hawaiian; M6 Small Business; M7 Disabled; M8 American Woman; M9 Black American Woman; and NM Not Minority.

(Must have greater than 51% minority ownership) "Minority/Woman Business Enterprises that file false misrepresentation of their MBE/WBE status shall be found guilty of a felony of the second degree and be debarred from bidding no less than 36 months pursuant to 287.094 Florida Statute".

EXHIBITS PAGE 10

EXHIBIT I

FINANCIAL ATTESTATION

This is not a request for your full financial statements; however, the College reserves the right to review your financial statement if such a review is in its best interest.

The requested data should be derived and/or calculated from the most recent financial statements prepared by an Independent Accounting Professional (IAP). (Examples of an IPA include the independent CPA, Tax accountant, and financial statement preparer or similar professional). The need for accurate financial information is important to the College. Providing false or grossly inaccurate information may disqualify you or your company from doing business with the College under this or future solicitations.

This form must be signed by the proposer and IAP that prepared and reviewed your firm’s most recent annual financial statement and be submitted with your response package.

1. Proposer Name:

2. Name of IAP that completed the review of your company’s most recent annual financial statement:

Is the Independent Accounting Professional preparing or assisting in the preparation of this worksheet, certified? ____ Yes or ____ No If certified, please indicate the certification of the IAP .

(i.e., CPA, CMA, CGMA, EA, etc.)

After review of the Consultant’s most recent audited financial/statement, as their IPA we have defined below:

1. Which year is the annual financial statement information being derived from?

2. Did the Proposer report a positive cash flow during the reporting year? ____ Yes ____ No

3. Did the proposer report a net after tax profit during that year? ____ Yes ____ No

4. The Proposer’s total assets are:

5. The Proposer’s total liabilities are:

6. The Proposer’s equity is:

“IAP” “PROPOSER”

Signature: Signature:

Name: Name:

Title: Title:

Date: Date:

EXHIBITS PAGE 11

EXHIBIT J

DISPUTES DISCLOSURE FORM SUMMARY OF LITIGATION

Answer the following questions by placing an “X” in the box after “YES” or “NO”. If you answer “YES”, please explain via attachment.

Disclosure can be limited to the regional/district office, which will be supporting this Contract.

1. Has your firm, or any of its officers, received a reprimand of any nature or been suspended by the Department of Professional Regulation or any other regulatory agency or professional association within the last five (5) years?

____ YES ____ NO

2. Has your firm, or any member of your firm, been declared in default, terminated or removed from a contract or job related to the services your firm provides in the regular course of business within the last five (5) years?

____ YES ____ NO

If YES, indicate company name, contact name, and telephone number, length of service provided, and reason for early cancellation/termination of contract.

3. Has your firm had filed against it or filed any requests for equitable adjustment, contract claims or litigation in the past five (5) years that is related to the services your firm provides in the regular course of business?

____ YES ____ NO

If YES, state the nature of the request for equitable adjustment, contract claim or litigation, a brief description of the case, the outcome or status of suit and the monetary amounts involved.

I hereby certify that all statements made are true and agree and understand that any misstatement or misrepresentation or falsification of facts shall be cause for forfeiture of rights for further consideration of this solicitation:

Printed or Typed Name Title

Authorized Signature (Officer) Date

EXHIBITS PAGE 12