Forms PDF.pdf

STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION

E-VERIFY

375-031-06

PROCUREMENT

OGC – 11/25

Contract No: DOT-ITB-26-7019-LV

Financial Project No(s): Various

Project Description: District-Wide Storm Drain Video Inspection Services

In accordance with the contract, the Vendor/Consultant/Contractor hereby acknowledges and certifies compliance with Section 448.095, Florida Statutes. The Vendor/Consultant/Contractor shall register with and use the E-Verify system to verify the work authorization status of all newly hired employees. The Vendor/Consultant/Contractor shall utilize the U.S. Department of Homeland Security’s E-Verify system, in accordance with the terms governing use of the system. The Vendor/Consultant/Contractor shall comply with Section 448.095, Florida Statutes, for the duration of the contract term, including any extensions or renewal periods.

Company/Firm:

Authorized Signature:

Title:

Date:

STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION

PERFORMANCE BOND

375-040-27

OGC – 10/04

KNOW ALL MEN BY THESE PRESENTS: That we, (name)

(hereinafter called Vendor) of (address) and

(hereinafter called Surety) of (name)

(address) duly authorized to do business in the State of Florida, are held and firmly bound unto the State of Florida in the full and just sum of Dollars ($ ), lawful money of the United States of America, to be paid to the Florida Department of Transportation (hereinafter called the Department), to which payment will and truly to be made we bind ourselves, our heirs, executors, administrators, successors and assigns, jointly and severally and firmly by these presents;

WHEREAS, the above Vendor has subscribed to an agreement with the Department to bear the date of

, for contractual services agreement in connection with FDOT District Seven Storm Drain Video

Inspection Services DOT-ITB-26-7019-LV in County(ies), particularly known as

(hereinafter called the Agreement), upon certain terms and conditions in said Agreement more particularly mentioned; and

NOW, THEREFORE, The condition of this obligation is such that if the above Vendor in all respects will comply with the terms and conditions of said Agreement, and its obligations thereunder, including the Scope of Services, Specifications, General Conditions, Special Conditions, Bid Blank therein referred to and made a part thereof, and such alterations as may be made in said conditions and specifications, as therein provided for; and, further, if such Vendor will promptly make payment to all persons supplying labor, material, equipment and supplies, used directly or indirectly by the said Vendor or any subcontractor(s) in the prosecution of the work provided for in said Agreement, and promptly will pay all State Workers' Compensation and Unemployment Compensation taxes incurred in the performance of the said

Agreement and will pay to the Department any amount in money or property, the Department may lose or be overcharged or otherwise defrauded of, by reason of any wrongful or criminal act of the Vendor, its agents, or employees, then this obligation is to be void; otherwise, to be and remain in full force and virtue in law.

WITNESS the signature of the Vendor and the signature of the Surety by its

(Agent or Attorney-in-Fact, or otherwise) with seals of said Vendor and Surety hereunto affixed this day of , .

Surety Vendor

BY: BY:

Signature Authorized Signature(s)

TITLE: TITLE:

Attorney-in-Fact/Agent (Surety Seal)

ATTEST:

Secretary/Notary

Name/Telephone #: BY:

Address: Signature

525-010-03

POLICY PLANNING

06/09

Note: Attach Power of Attorney showing authority of Surety’s Agent or Attorney-in-Fact. This bond is not for public works contracts required by Section 25.05, Florida Statutes.

Florida Statutes:

287.135

STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION

VENDOR CERTIFICATION REGARDING

SCRUTINIZED COMPANIES LISTS

375-030-60

OGC – 08/25

Respondent Vendor Name:

Vendor FEIN:

Vendor’s Authorized Representative Name and Title:

Address:

City: State: Zip:

Phone Number:

Email Address:

Section 287.135, Florida Statutes, prohibits a company or other entity from bidding on, submitting a proposal for, or entering into or renewing a contract for goods or services of: i) $100,000 or more if, at the time of bidding on, submitting a proposal for, or entering into or renewing such contract, the company or other entity is on the Scrutinized Companies or Other Entities that Boycott Israel List, created pursuant to Section 215.4725, Florida Statutes, or is engaged in a boycott of Israel; and, ii) $1,000,000 or more if, at the time of bidding on, submitting a proposal for, or entering into or renewing such contract, the company or other entity is on either the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Terrorism Sectors List, created pursuant to Section 215.473, Florida Statutes, or is engaged in business operations in Cuba or Syria.

As the authorized representative of the company or other entity identified above in the section entitled “Respondent Vendor Name”, I hereby certify that the company or other entity is not listed on either the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Terrorism Sectors List, or the Scrutinized Companies or Other Entities that Boycott Israel List. I further certify that the company or other entity is not engaged in a boycott of Israel and is not engaged in business operations in Cuba or Syria. I understand that pursuant to Section 287.135, Florida Statutes, the submission of a false certification may subject the company to civil penalties, attorney’s fees, costs, and/or ineligibility to bid on future contracts.

Certified By:

who is authorized to sign on behalf of the above referenced company.

Authorized Signature Print Name and Title:

Date: