FSA25-TRS27.0_Qualification_Packet.pdf

FSA Cooperative Purchasing Program

Qualifications Packet

FSA Contract Number:

Bidder Company Name:

QUALIFICATIONS FORM

Each Bidder shall complete and submit the Bidder’s qualifications form. FSA reserves the right to request documentation confirming the provided information.

FSA Contract Number:

Contact Information Bidder’s registered Entity Name:

Parent Company, if applicable:

Business Address:

The individuals below will be the points of contacts for FSA during the bid process. If awarded, the Bidder will need to complete an online contact form to provide FSA staff with the appropriate contacts for servicing this contract.

Primary Contact (Authorized Agent):

Name:

Title:

Phone number:

Email:

Secondary Contact: Name:

Title:

Phone number:

Email:

Business Profile Federal Employer Identification Number (FEIN):

State of Incorporation:

Length of Time in Business (Years):

Check:

Manufacturer Dealer

If dealer, are you an authorized/certified dealer for the manufacturer of the products that you will be bidding on? Yes No

Select the applicable boxes:

Individual Partnership Corporation

LLC

Does the Bidder meet the requirements for any of the following designations?

Minority Business Enterprise (MBE) Disadvantaged Business Enterprise (DBE) Women Business Enterprise (WBE) Small Businesses Enterprise (SBE)

References Provide three references from contracts of comparable size and scope. If Bidder does not have experience of comparable size and scope, business references may be provided.

Select if Bidder is currently an FSA awarded vendor. References not required for current vendors.

Contracting Entity:

Term of Contract:

Is this a government fleet sales contract?

Yes No Select type of reference (select all that apply):

Contracting Entity:

Term of Contract:

Is this a government fleet sales contract?

Yes No Select type of reference (select all that apply):

Disqualifications & Defaults

List the contracts the Bidder has been disqualified, terminated, or found in default on within the last five

(5) years. Explanations must be provided.

Contracting Entity:

Date of occurrence:

Is this a government fleet sales contract?

Yes No The Bidder was (select all that apply):

Explanation of disqualification, termination, and default.

Contracting Entity:

Date of occurrence:

Is this a government fleet sales contract?

Yes No

The organization maintains a repair facility within the State of Florida.

The organization does NOT maintain a repair facility within the State of Florida.

If not: Does your organization have a Warranty Service Plan to service Florida purchasers if awarded the contract? Yes No

The Bidder was (select all that apply):

Explanation of disqualification, termination, and default.

Contracting Entity:

Date of occurrence:

Is this a government fleet sales contract?

Yes No

The Bidder was (select all that apply):

Explanation of disqualification, termination, and default.

Warranty Service Plan The bidder attests that:

COMPLIANCE ATTESTATIONS

The following items are required and governed by Florida statute, or Federal law, as applicable.

E-Verify Per Florida Statute 448.095 public employers, Bidders, and sub-vendors must register with and use the E-Verify system operated by the U.S. Department of Homeland Security to verify the work authorization of all newly hired employees.

As the representative for , I hereby attest that (please choose one):

Yes, our organization meets the Florida requirements for E-Verify.

No, our organization does not meet the Florida requirements for E-Verify.

Workers Compensation Per Florida Statute Chapter 440, employers must provide workers’ compensation insurance for their employees.

, I hereby

As the representative for attest that (please choose one):

Yes, our organization meets the Florida requirements for Workers Compensation.

No, our organization does not meet the Florida requirements for Workers Compensation.

FSA Contract Number:

Bidder Company Name:

The Bidder is registered in SunBiz to do business in the state of Florida.

Bidder's registered Entity Name is:

The Bidder will be registered in SunBiz to do business in the state of Florida by the time of award. Upon award, Bidder will provide FSA with its registered Entity Name.

SunBiz Registration Attestation The Bidder attests that:

Drug-Free Workplace The Bidder attests that they operate in accordance with Florida Statute 287.087 (Drug-Free Workplace), to make a good faith effort to maintain a drug-free workplace through implementation of best practices identified below.

• Publish and provide 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.

http://www.leg.state.fl.us/statutes/index.cfm?mode=View%20Statutes&SubMenu=1&App_mode=Display_Statute&Search_String=448.095&URL=0400-0499/0448/Sections/0448.095.html http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0400-0499/0440/0440ContentsIndex.html

As the representative for , I hereby attest that (please choose one):

Yes, our organization meets the requirements of a drug-free workplace.

No, our organization does not meet the requirements of a drug-free workplace.

Compliance with Applicable Federal, State, and Local Laws and Ordinances Bidder must comply with all applicable Federal, State, and Local Laws and Ordinances. For example, to sell or distribute motor vehicles in the state of Florida, Bidders must possess the appropriate Motor Vehicle Dealer and Brokers license as outlined by the Florida Department of Highway Safety & Motor Vehicles.

The Bidder sells or distributes motor vehicles in the State of Florida, and complies with all Federal, state, and local government requirements applicable to Bidder, including any requirement for appropriate Motor Vehicles Dealer license.

The bidder does not sell or distribute motor vehicles in the State of Florida and complies with all Federal, state, and local government requirements applicable to Bidder, including any requirements for an appropriate Motor Vehicles Dealer license in the state(s) in which the Bidder does sell or distribute motor vehicles, as applicable.

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

• Notify employees, that as a condition of working on the FSA contract, 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 Chapter 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.

https://www.flhsmv.gov/motor-vehicles-tags-titles/dealers-installers-manufacturers-distributors-importers/mv-rv-mh-dealer-broker-licenses/types-of-licenses-available/ https://www.flhsmv.gov/motor-vehicles-tags-titles/dealers-installers-manufacturers-distributors-importers/mv-rv-mh-dealer-broker-licenses/types-of-licenses-available/

Click or tap here to enter text.

Insurance Checklist

The Insurance Checklist outlines the Bidder’s insurance coverage obligations, if awarded. Complete insurance requirements are in the terms and conditions.

1. Comprehensive General Liability

• Minimum limits of $1,000,000 per occurrence to include:

o Bodily Injury o Property Damage o Contractual Liability o Completed Products/Operations

• General Aggregate o Minimum limit of $2,000,000

2. Automobile Liability

• Minimum limit of $1,000,000 per occurrence to include:

o Owned, non-owned, hired, scheduled automobiles

3. Garage Keepers Liability

• Minimum limit of $1,000,000 o Applicable when the bidder’s garage will be used to complete work under this contract; inclusive of upfitting and/or warranty service.

o If bidder does not have garage keepers insurance, a reason must be provided on company letterhead.

4. The Florida Sheriffs Association (FSA) must be listed as an Additional Insured

5. The certificate must include the FSA bid number and bid title.

Bidder understands the insurance requirements of the contract terms and conditions, and that if awarded evidence of insurance is required five (5) business days prior to the contract award date.

FSA Bid Number:

Bidder Name:

Signature:

Date: