FSA25-VEF19.0_-_Qualification_Packet.pdf

FSA Cooperative Purchasing Program

Qualification Packet

FSA Contract Number Bidder Company Name

QUALIFICATIONS FORM

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

FSA Contract Number

Contact Information Bidder Company Name

Parent Company, if applicable

Business Address

The individuals below will be the point 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 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:

Emergency Vehicle Technician (EVT) Certification Bidders that will provide or contract to provide emergency light and siren installation must only use installers that possess a current Emergency Vehicle Technician Certification. FSA may request certificates for a vendor’s installers at any time during the contract term. For vehicles that are manufactured with emergency lights and sirens, including motorcycles, bidders may not charge for labor.

☐ The bidder attests that emergency light and siren installations are only done by installers that possess a current Emergency Vehicle Technician Certification.

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

Ambulance Remount Services Ambulance remount services may be offered by awarded vendors. Bidders offering ambulance remount services must meet all current standards and requirements established by the Commission on Accreditation of Ambulance Services Ground Vehicle Standards (CAAS GVS).

☐ The bidder will offer ambulance remount services and will comply with the requirements outlined in Section 3.13 of the Contract Terms and Conditions, including:

• Must be registered with the National Highway Traffic Safety Administration (NHTSA) as a vehicle manufacture

• Maintain the required insurance policies and limits

• Meet the minimum warranty requirements

• Follow all recommended guidelines and practices as published and prescribed by the OEM chassis manufacturer for the chassis platform supplied

☐ The bidder will not offer ambulance remount services.

FLORIDA COMPLIANCE

The following items are required and governed by Florida statute.

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.

As the representative for , I hereby 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.

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.

SunBiz Registration Attestation The Bidder attests that:

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.

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 http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0200-0299/0287/Sections/0287.087.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.

• 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.

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.

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/

FEDERAL COMPLIANCE

Bidders willing to accept purchase orders that are funded in whole or in part with federal funding (e.g., federal grants or cooperative agreements), have the option to agree to comply with applicable federal regulations. This is encouraged; however, not a requirement of the bid.

As the representative for , I certify that my organization (please choose one):

Is willing to comply with the requirements applicable to federally funded purchase orders set forth in the FSA CPP Terms & Conditions Appendix D.

Is not willing to comply with the requirements applicable to federally funded purchase orders set forth in the FSA CPP Terms & Conditions Appendix C. I understand that this means purchasers will not be able to order my products using federal funds.

Bidder Company Name:

Name of Authorized Agent:

Business Address:

Signature:

Date:

Debarment and Suspension *Required for Bidders opting-in for federal compliance This contract is a covered transaction for purposes of 2 CFR Part 180. As such, the Bidder is required to verify that none of the Bidder’s principals (defined at 2 CFR § 180.995) or its affiliates (defined at 2 CFR § 180.905) are excluded (defined at 2 CFR § 180.940) or disqualified (defined at 2 CFR § 180.935) or listed on the governmentwide exclusions in the System for Award Management (“SAM”). SAM Exclusions contain the names of parties debarred, suspended, or otherwise excluded by agencies, as well as parties declared ineligible under statutory or regulatory authority other than Executive Order 12549.

The Bidder must comply with 2 CFR Part 180 and must include a requirement to comply with these regulations in any lower tier covered transaction it enters into. This certification is a material representation of fact relied upon by the Florida Sheriffs Association. If it is later determined that the bidder did not comply with 2 CFR Part 180 in addition to remedies available to the Florida Sheriffs Association, the Federal Government may pursue available remedies, including but not limited to suspension and/or debarment.

The Bidder agrees to comply with the requirements of 2 CFR Part 180 while this offer is valid and throughout the period of any contract that may arise from this offer. The Bidder or proposer further agrees to include a provision requiring such compliance in its lower tier covered transactions.

The Bidder hereby attests that it is not identified in the Exclusions area of SAM as being currently debarred, suspended, proposed for debarment or otherwise excluded and the Bidder will comply with the requirements of 2 CFR Part 180.

Bidder Company Name:

Name of Authorized Agent:

Signature:

Lobbying Certification for Contracts, Grants, Loans and Cooperative Agreements *Required for Bidders opting-in for federal compliance

No federal appropriated funds have been paid or will be paid, by or on behalf of the Bidder, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.

If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the bidder shall complete and submit Standard Form- LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions.

The Bidder shall require that the language of this attestation be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly.

This attestation is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by 31, U.S.C. § 1352 (as amended by the Lobbying Disclosure Act of 1995). Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

The Bidder attests the truthfulness and accuracy of each statement of its certification and disclosure, if any. In addition, the Bidder understands and agrees that the provisions of 31 U.S.C. § 3801 et seq., apply to this certification and disclosure, if any.

The Bidder hereby attests that it has not used and will not use Federal appropriated funds to pay any person or organization for influencing or attempting to influence an officer or employee of any agency, a member of Congress, officer or employee of Congress, or an employee of a member of Congress in connection with obtaining any Federal contract, grant or other award covered by 31 U.S.C. § 1352 and the Bidder understands and agrees to comply with the provisions of 31 U.S.C.

§ 3801 et seq.

Bidder Company Name:

Name of Authorized Agent:

Signature:

Date:

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

• Product Liability o Minimum limit of $5,000,000 required for all bidders providing ambulance remount services

2. Automobile Liability

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

o Owned, non-owned, hired, scheduled automobiles o Applicable if items are transported or delivered to purchasers by the bidder

3. Garage Keeper’s Liability

• Minimum limit of $1,000,000 o Required for all bidders providing ambulance remount services.

o Applicable when the bidder’s garage will be used to complete work under this contract;

inclusive of upfitting and/or warranty services.

o If bidder does not have garage 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:

INSURANCE CHECKLIST