Form_4_Local_Vendor_Preference_Certification.pdf

Version 2 9.2.25

Procurement Services Division

Form 4: Local Vendor Preference Certification

(Check Appropriate Boxes Below)

State of Florida (Select County if Vendor is described as a Local Business) Collier County Lee County

Vendor affirms that it is a local business as defined by Section Sixteen of the Collier County Procurement Ordinance:

• A physical business address in Collier County with a County business address as listed with the Florida Department of State, Division of Corporations located within the limits of Collier County from which the vendor's staff operates and performs business in an area zoned for the conduct of such business. A post office box or a facility that receives mail, or a non-permanent structure such as a construction trailer, storage shed, or other non-permanent structure shall not be used to establish the physical address. In addition to the foregoing, a vendor shall not be considered a "local business" unless it contributes to the economic development and well-being of Collier County in a verifiable and measurable way. This may include, but not be limited to, the retention and expansion of employment opportunities, support and increase to the County's tax base, and residency of employees and principals of the business within Collier County. Vendors shall affirm in writing their compliance with the foregoing at the time of submitting their bid or proposal to be eligible for consideration as a "local business" under this section. A vendor who misrepresents the Local Preference status of its firm in a proposal or bid submitted to the County will lose the privilege to claim Local Preference status for a period of up to one year; and

• A current local Business Tax Receipt (also known as an Occupational License) issued by the Collier County Tax Collector prior to bid or proposal submission.

If requested by the County, Vendor will be required to provide documentation substantiating the information given in this certification. Failure to do so will result in the vendor’s submission being deemed non-responsive.

Under penalties of perjury, I certify that the information shown on this form is correct to my knowledge and a duly corporate authorized representative with signature authority.

Company Name: _________________________________________

Date: _____________________________

Signature: ____________________________________________ Title: _____________________________