FSA26EQU24.0_Qualification_Packet_1.pdf

FSA Contract Number:

Bidder’s Entity: 1

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 Entity:

Parent Company, if applicable:

Business Address:

The individuals below will be the points of contact for FSA during the bid process. The primary contact must be an authorized agent permitted to sign on behalf of the bidding company.

Primary Contact (Authorized Agent):

Name:

Title:

Phone number:

Email:

Secondary Contact:

Name:

Title:

Phone number:

Email:

Business Profile DBA, if applicable:

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

Bidder’s Entity: 2

Select registered company type:

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 two 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 If the Bidder has been disqualified, terminated, or found in default on a contract within the last five (5) years, provide the contract information below. An explanation must be provided.

Contracting Entity:

Date of occurrence:

Is this a government fleet sales contract?

Yes No

Bidder’s Entity: 3

The Bidder was (select all that apply):

Explanation of disqualification, termination, or default:

Bidder’s Authorized Dealer Listing

Bidder’s Authorized Dealer Name Address (Street, City, ZIP) Telephone # E-Mail

Bidder’s Entity: 4

FLORIDA STATUTE COMPLIANCE ATTESTATIONS

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

SunBiz Registration Attestation The Bidder attests that:

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

Bidder's Entity:

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.

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.

Anti-Human Trafficking Affidavit As the representative for , I hereby attest as follows:

1. I am over 21 years of age and an officer or representative of the Bidder.

2. The Bidder does not use coercion for labor or services as defined in Section 787.06(2)(a), Florida

Statutes.

3. More particularly, the Bidder does not participate in any of the following actions:

a. Using or threatening to use physical force against any person;

b. Restraining, isolating or confining or threatening to restrain, isolate or confine any person without lawful authority and against her or his will;

c. Using lending or other credit methods to establish a debt by any person when labor or services are pledged as a security for the debt, if the value of the labor or services as reasonably assessed is not applied toward the liquidation of the debt or the length and nature of the labor or services are not respectively limited and defined;

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=0700-0799/0787/Sections/0787.06.html http://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&URL=0700-0799/0787/Sections/0787.06.html

Bidder’s Entity: 5

d. Destroying, concealing, removing, confiscating, withholding, or possessing any actual or purported passport, visa, or other immigration document, or any other actual or purported government identification document, of any person;

e. Causing or threatening to cause financial harm to any person;

f. Enticing or luring any person by fraud or deceit; or

g. Providing a controlled substance as outlined in Schedule I or Schedule II of Section

893.03, Florida Statutes, to any person for the purpose of exploitation of that person.

Yes, our organization meets the Florida requirements for Anti-Human Trafficking.

No, our organization does not meet the Florida requirements for Anti-Human Trafficking.

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.

If you checked “No”, please provide exemption approval from the Florida Department of Financial Services (FLDFS) Division of Worker’s 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.

• 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 http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0800-0899/0893/Sections/0893.03.html http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0800-0899/0893/Sections/0893.03.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

Bidder’s Entity: 6 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.

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. In order to sell motor vehicles in the state of Florida, Bidders must possess a Motor Vehicle Dealer license issued by the Florida Department of Highway Safety & Motor Vehicles.

The Bidder sells motor vehicles in the State of Florida and has a Motor Vehicles Dealer license issued by the Florida Department of Highway Safety & Motor Vehicles.

License Number:

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.

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

Bidder’s Entity: 7

FEDERAL COMPLIANCE

Bidders willing to accept purchase orders that are funded in whole or in part with federal funding have the option to agree to comply with applicable federal regulations. This is encouraged; however, not required.

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 and Conditions Appendix D.

Is not willing to comply with the requirements applicable to federally funded purchase orders set forth in the FSA CPP Terms and Conditions Appendix D.

Bidder’s Entity:

Name of Authorized Agent:

Select registered company type:

Individual Partnership Corporation

LLC

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

Bidder’s Entity: 8 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’s Entity:

Name of Authorized Agent:

Select registered company type:

Individual Partnership Corporation

LLC

Business Address:

Signature:

Date:

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

Bidder’s Entity: 9

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’s Entity:

Name of Authorized Agent:

Bidder’s Entity: 10

Select registered company type:

Individual Partnership Corporation

LLC

Business Address:

Signature:

Date:

Bidder’s Entity: 11

NOTARY ACKNOWLEDGEMENT

Statement of Certification As the representative for , I hereby certify that, to the best of my knowledge, all information provided in the Qualification Packet for the FSA26-EQU24.0: Equipment Invitation to Bid, and subsequent Contract, is true and accurate.

Bidder’s Entity:

Name of Authorized Agent:

Select registered company type:

Individual Partnership Corporation

LLC

Business Address:

Signature:

Date:

Notary Certificate

STATE OF FLORIDA

COUNTY OF _______________________

SWORN TO AND SUBSCRIBED before me ☐ physical presence or ☐ remote notarization by _________________________, as an authorized agent of ____________________________, who is personally known to me or who produced __________________________ as identification this _____ day of _________________, 2026.

Notary Public

(Notary Seal)