Hardware for Lasers (B002838).docx

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Attached to
Hardware for Lasers State and local contract opportunity
Solicitation number
B002838
Issued by
Madison County, Alabama

About this file

This is a formal bid document (B002838) issued by the University of Alabama in Huntsville (UAH) Procurement Services for Hardware for Lasers. The solicitation requests bids for 36 specific hardware components and accessories for laser equipment, with varying quantities ranging from 1 to 20 units per item. The bid response is due by 07/26/2024 at 1:30 PM, and all bids must be submitted electronically via BidNet Direct. The contract term is initially one year with options to renew for four additional one-year periods, contingent upon satisfactory performance evaluations. Delivery will be F.O.B. to UAH's Central Receiving Building in Huntsville, Alabama.

The bid allows for potential contract extension to other University of Alabama System entities, including UAB and main campus in Tuscaloosa. Bidders are required to provide detailed product specifications and are advised that the University reserves the right to accept or reject any bid based on factors including service, integrity, facilities, equipment, reputation, and past performance. The total estimated value of the hardware is not explicitly stated, but the bid covers a comprehensive list of precise laser and optical equipment components. Pricing must include all shipping charges, and the University does not guarantee any specific purchase quantity, with orders to be placed on an as-needed basis.

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THE UNIVERSITY OF ALABAMA IN HUNTSVILLE

PROCUREMENT SERVICES

301 SPARKMAN DRIVE

HUNTSVILLE, ALABAMA 35899

PHONE (256) 824-6484

ALL BIDS WILL BE PUBLICLY OPENED ON THE OPENING DATE DESIGNATED AT THE UNIVERSITY OF ALABAMA IN HUNTSVILLE, PROCUREMENT SERVICES, BUSINESS SERVICES BLDG., HUNTSVILLE, ALABAMA 35899. BIDS RECEIVED AFTER THE SPECIFIED TIME ON THE OPENING DATE WILL NOT BE CONSIDERED.

BID NUMBER

B002838

DATE

07/15/2024

RESPONSE DUE BY:
07/26/2024

1:30 PM

REQUEST FOR FORMAL BID

CONTACT PHONE VENDOR NO.PAMELA HURLEY 256-824-6675 «vendornum»

ALL BID RESPONSES ARE REQUIRED TO BE SUBMITTED

ELECTRONICALLY VIA BIDNET DIRECT. NO BID RESPONSES

WILL BE ACCEPTED VIA US MAIL, FAX, OR EMAIL. FAILURE

TO COMPLY WILL RESULT IN A “NO BID”

RESPONSE IN ACCORDANCE WITH ALABAMA COMPETITIVE

BID LAW 41-16-24 sub-part b.

V E N D O

RTHE ABOVE BID NUMBER MUST APPEAR ON ALL BIDS AND RELATED CORRESPONDENCE

OR EQUAL, REFER TO GENERAL CONDITIONS ON ATTACHED SHEET

NO

QUANTITY

UNIT

DESCRIPTION

UNIT PRICE

EXTENSION

TOTAL

THE UNIVERSITY OF ALABAMA IN HUNTSVILLE REQUESTS BIDS FOR Hardware for Lasers AS PER THE SPECIFICATIONS.

All bid responses are required to be submitted electronically via BidNet Direct. No bid responses will be accepted via fax or email.

AWARD:

NO AWARD INFORMATION WILL BE MADE

AVAILABLE BY TELEPHONE, FAX, MAIL, OR EMAIL.

ONCE THE BID IS AWARDED, THE AWARD

INFORMATION AND TABULATION WILL BE POSTED

TO OUR WEBSITE THROUGH BIDNET DIRECT.

HTTPS:/BIDNETDIRECT.COM/ALABAMA/UNIVERSITY OFALABAMAINHUNTSVILLE CLICK ON

SOLICITATIONS).

SHOULD A PURCHASE ORDER BE ISSUED, THE FOREGOING AND THE TERMS AND CONDITIONS ON THE ATTACHED SHEET SHALL BE APPLICABLE AND BINDING UPON THE VENDOR.

I ACKNOWLEDGE THAT I HAVE SIGNATURE AUTHORITY TO SIGN ON BEHALF OF THE COMPANY AND HEREBY AGREE TO ALL GENERAL CONDITIONS OF THIS BID REQUEST.

SIGNATURE ________________________________________________ DATE____________________________ PAGE 1 COMPANY REPRESENTATIVE An Affirmative Action/Equal Opportunity Institution

THE UNIVERSITY OF ALABAMA IN HUNTSVILLE (University) requests bids for Hardware for Lasers listed below per the specification below:

Bid Prices are to include all shipping charges. (FOB: Destination)

Delivery may be a factor in determining the award of this bid. Quote earliest possible delivery after receipt of purchase order: ____________________

The successful bidder shall not substitute any ordered item without the prior approval of the University. Unauthorized substitutions shall not be acceptable.

The University reserves the right to increase or decrease quantities as needed according to the availability of funds.

The University reserves the right to accept or reject any or all bids and is not necessarily bound to accept the lowest bid if that bid is contrary to the best interest of the University. (See GENERAL CONDITIONS 1. AWARD) NOTE: For information regarding bid responses, it is the bidder’s responsibility to provide in detail clear proof that the products they are bidding on are equal to or better than the requirements of the invitation. The bidder is responsible for clearly and specifically indicating the product being offered and to provide sufficient descriptive literature, catalog cuts, and technical details to enable UAH to determine if the product offered meets the requirements of the invitation. Normally as in competitive sealed bidding only, the information furnished with the bid will be considered in the evaluation. Failure to furnish adequate data for evaluation purposes may result in declaring a bid nonresponsive. Unless the bidder clearly indicates in its bid that the product offered is an “EQUAL” product, such bid will be considered to offer the brand name product referenced in the invitation. The University will be the sole judge of “EQUAL” items submitted for bid.

"Any contract resulting from this request will be made available to other eligible entities. This may include but is not limited to; The University of Alabama System, comprised of The University of Alabama; The UAB Enterprise, consisting of The University of Alabama at Birmingham, the UAB Health System and their related foundations and affiliates, and The University of Alabama, Tuscaloosa, AL; and other state entities. Contracts resulting from the award of this request cover shipments by any entity listed above. Each entity will generate its own purchase orders, payments, etc. and delivery must be made according to the instructions on the purchase order.

The thrust of the contract is to obtain greater volume price discounts by combining the volume of purchases from participating entities within the State of Alabama.”

**NOTE: Bidders are requested to price all items. If your company does not stock an item please quote and equal. If your company does not have an equal item please indicate by N/A.

The quantity purchased for any particular item may fluctuate from zero units to an excess of units. The University does not guarantee any specific quantity will be purchased during the contract period. All orders will be placed on an as-needed basis.

QUESTIONS: ALL QUESTIONS ARE TO BE DIRECTED TO THE BIDNET DIRECT VIA THE BID

NUMBER UNLESS OTHERWISE STATED IN THE SPECIFICATION.

Hardware for Lasers Specifications

Qty
Price
Extended Total
1
Right Angle Plate AP90
1
2
¼-20 Stainless Steep Cap Screw 3/8” Long Pack of 25 SH25S038
4
3
Series Spanner Wrench SPW603
2
4
1/4-20 x 3/8 Low Profile Cap Screw, Box of 100 1/4-20 x 3/8 Low Profile Cap Screw, Box of 100 SH25LP38
1
5
Angle Bracket XE25A90
8
6
20-Inch-Long Structural Rail XE25L20
10
7
24-Inch-Long Structural Rail XE25L24
20
8
3/16 Black Hard Board, 3 Sheets 24X24 TB4
10
9
25.4mm NP 50:50 Beam splitter Cube 400-700nm BS013
2
10
1 inch Construction Cube, Clearance Holes TTN023537 RM1G
16
11
Miniature ½ inch Translator TTN010447, 6639 T12XY
2
12
01” 50:50 R:T UVFS Plate Beam splitter, 400-700nm, t+5mm BSW10
2
13
Aluminum Breadboard Density 6” X 12” X ½” ¼”-20 MB612
4
14
Large Area Translation Stage 6” X 5.95” TBB0606
2
15
01”30:70 (R:T) UVFS Plate Beam Splitter, 400-700nm, t=5mm BSS10
2
16
Mounted AC127-030-C-01”, efl=300mm AC127-030-C-ML
4
17
Mounted AC254-300-C-01”, efl=300mm AC254-300-C-ML
2
18
Mounted AC 127-030-A-00.5”, efl=300mm AC127-030-A-ML
2
19
Mounted AC254-300-A - Ø1.0" , efl=300mm AC254-300-A-ML
2
20
45deg Post Clamp RA45
5
21
25.0mm Knife-Edge Right-Angle Prism Mirror, -P01 Coating MRAK25-P01
4
22
12.7mm NP 50:50 Beam splitter Cube 1100-1600nm BS006
2
23
½” Dia. X3” Length: Pack of 5 Post TR3-P5
5
24
TBB Adaptor Plate 6” TBBA0606
1
25
C-Mount Extension Tube Kit CML-KIT
1
26
C-Mount Brass Spacer Kit CMSP-KIT
1
27
Vertical Adjustment Platform, 10in Travel TTN047992 VAP10
1
28
135 Degree Post Clamp RA135
5
29
SM05 Rotating Lens Tube, 1.0” Long SM05V10
4
30
3” Universal Post Holder-5 Pack 2877 UPH3-P5
5
31
30:70 (R:T) Non-Pol Beam splitter Cube, 1100-1600nm, 5mm BS048
2
32
30:70 (R:T) Non-Pol Beam splitter Cube, 1100-1600 nm, 10 mm BS051
2
Qty
Price
Extended Total
33
SM05 Components Essential Kit, Universal Components ESK24
1
34
90 Degree Gusset Plate for XE25 to rail XE25GP
16
35
T Gusset Plate for XE25 Rail XE25GP2
8
36
Spanner Wrench for SM05-Threaded Retaining Rings, Graduated, Spanner Wrench for SM05-Threaded Retaining Rings, Graduated Scale with 0.1” (2.5mm) SPW603L
2

Total

GENERAL CONDITIONS

1. Award: The University of Alabama in Huntsville (University) reserves the right to accept or reject any or all bids and is not necessarily bound to accept the lowest bid if that bid is contrary to the best interest of the University. In making an award, intangible factors such as the bidder’s service, integrity, facilities, equipment, reputation, and past performance will be weighed along with the quality displayed in the samples submitted. Bids may be awarded either item by item low, group or total low, in product groups, or all or none, whichever appears to be in the best interest of the University. The bid may be awarded by Group A and Group B to different Vendors. The University reserves the right to waive any or all formalities.

The bid may be awarded to a Primary Vendor (which may be the lowest Vendor meeting all Specifications) and a Secondary Vendor (which may be the second lowest-priced Vendor meeting all Specifications).

2. Bid Withdrawal: No bids may be withdrawn without approval from the University Procurement Services. Any withdrawal requests must be in writing to Procurement Services within five (5) days after the opening date with justification for the reason for withdrawal. More than two (2) such requests could result in removal from our bid list. No bid may be withdrawn after the issuance of a purchase order. If a withdrawal is made after the purchase order is issued, the vendor will be considered in default. Refer to “Default of Contractor”.

3. Prices and Payment Terms: Bidders should quote applicable cash discounts. The University will not take into consideration in bid evaluation any cash discount of less than thirty (30) days duration. However, we will take advantage of all discounts for which we are eligible. Identify these discounts in your bid response. Bids containing “payment in advance” or “COD” requirements may be rejected.

4. Contract Term:

As mutually agreed, upon, the successful Proposer shall be awarded a Contract for one (1) year with the option to renew the Contract for four (4) additional one-year periods and under the same terms and conditions, if it should be deemed advisable and advantageous. Renewal of this Contract shall be contingent upon annual satisfactory performance evaluations by the University.

5. Applicable Law: It is agreed this quotation is valid to the extent that it does not violate the constitution or the laws of the State of Alabama.

Bidder represents and warrants that all article and services covered by this bid meet or exceed the safety standards established and promulgated under the Federal Occupational Safety and Health Act of 1970, No. 2006, and its regulations in effect or proposed as of the date of this bid.

The furnishing of materials, supplies, equipment or service to the University under this purchase order, contract, solicitation for bids, or construction specification constitutes assurance by the vendor or contractor of his compliance with applicable provisions of and pertinent regulations promulgated under Executive Order 11246, date September 28, 1965 issued by the President of the United States of America, and Public Law 88-352, 88th Congress, the “Civil Rights Act of 1964”.

6. Non-Collusion: Any agreement or collusion among bidders or prospective bidders in restraint of freedom of competition, by agreement to bid at a fixed price or to refrain from bidding, or otherwise, shall render the bids of such bidders’ void. Each bidder certifies that he has not been a party to such an agreement by signing this bid.

7. New Products: Unless specifically called for in the bid, all products for purchase must be new, never previously used, and the current model and/or packaging. No remanufactured, demonstrator, used, or irregular product will be considered for purchase unless otherwise specified in the bid. The manufacturer’s standard warranty will apply unless otherwise specified in the bid. All requests should be supplied complete, ready to be installed, including all cabling and connectors where applicable.

8. Bonds: Bid and performance security bond, when required will be indicated.

9. Bid Submission: Failure to submit a bid on the official UAH Bidnet Direct website provided for that purpose shall be a cause for rejection of the bid. Return of the complete document is required. Modification of or additions to any portion of the solicitation may be cause for rejection of the bid; however, UAH reserves the right to decide, on a case-by-case basis, in its sole discretion, whether or not to reject such a bid as non-responsive.

All information shall be entered in ink or typewritten in the appropriate space on the form. Mistakes may be crossed out and corrections inserted before submission of your bid. Corrections shall be initialed in ink by the person signing the bid.

All bids must be signed. Failure to do so will result in rejection of bid.

10. Delivery: Time of delivery shall be stated as the number of calendar days following receipt of the order by the vendor, to receipt of the goods by the University.

Delivery time may be a criterion in awarding bids. Specify earliest possible delivery after receipt of order.

Failure to deliver within the time vendor specified in the bid will constitute a default and may cause cancellation of the contract. Refer to “Default of Contractor”.

All prices quoted are to be F.O.B. delivered to the University, Central Receiving Building, 301 Sparkman Drive, Huntsville, Alabama, 35899 (unless another F.O.B. point is stated by the University on bid form). The successful bidder must assume all responsibility for damage in transit. When installation is required, it will be stated. If you are not quoting a delivered price, indicate your shipping point, and provide shipping cost for evaluation purposes.

11. Bid Terms: Show unit prices, extensions, and total price. In the event of a discrepancy between the unit price and the extension, the unit price shall govern. Bids shall remain firm for minimum thirty (30) days from date of bid opening and any exception must be clearly stated.

12. Bid Opening: Bidders may attend the bid opening, but no information or opinions concerning the ultimate award will be given at the bid opening or during the evaluation process. After the public opening of this bid, the results will not be available to bidders not attending the opening until after an award is made. Bid tabulations can be reviewed by accessing Procurement Services website at http:/bidnetdirect.com/Alabama/Universityofalabamainhuntsville . Click on Closed Solicitations.

13. Bids are Public Record: All bids become a matter of public record at bid award. The University accepts no responsibility for maintaining the confidentiality of any information submitted with the bid whether labeled confidential or not.

14. Standards of Quality: When a material, article or piece of equipment is identified in these specifications by reference to manufacturer’s or vendor’s name, trade name, catalog and stock numbers, etc., it is intended merely to establish a standard; and, any material, article or equipment of other manufacturer and vendor which will perform equally the duties imposed by the general design, provided the material, article, or equipment proposed, is in the opinion of the Purchasing Agent of equal substance and function. It shall not be purchased or installed by the contractor without the Purchasing Agents’ written approval.

The bidder is responsible to clearly and specifically indicate the product being offered and to provide sufficient descriptive literature, catalog cuts and technical detail to enable UAH to determine if the product offered meets the requirements of the invitation. Normally in competitive sealed bidding only the information furnished with the bid will be considered in the evaluation. Failure to furnish adequate data for evaluation purposes may result in declaring a bid nonresponsive. Unless the bidder clearly indicates in its bid that the product offered is an “Equal” product, such bid will be considered to offer the brand name product referenced in the invitation. The University will be sole judge of EQUAL items bid.

15. Vendor Authorization: Vendor must be an authorized distributor/agent to sell products proposed in this bid request. When it is deemed to be in the best interest of the University, Procurement Services may request an on-site premise visit to examine the facility.

16. Default of Contractor: Where the University has determined the contractor to be in default, the University reserves the right to purchase any or all products or services covered by the contract on the open market and to charge the contractor with cost in excess of the contract price. Until such assessed charges have been paid, no subsequent bid from the defaulting contractor will be considered.

17. Fiscal Funding Clause: The continuation of this contract is contingent upon the appropriation of funds to fulfill the requirements of the contract by the legislature. If the legislature fails to appropriate sufficient monies to provide the continuation of a contract, the contract shall terminate on the date of the beginning of the first fiscal year for which funds are not appropriated.

18. Contract Cancellation: Procurement Services has the right to cancel any contract, in accordance with Purchasing Rules and Regulations, for cause, including, but not limited to, the following: (1) failure to deliver within the contract; (2) failure of the product or service to meet specifications, conform to sample quality, or to be delivered in good condition; (3) misrepresentation by the contractor; (4) fraud, collusion, conspiracy, or other unlawful means of obtaining any contract with the state; (5) conflict of contract provisions with constitutional or statutory provisions of state or federal law; and (6) any other breach of contract.

19. Warranties: Should merchandise described on this bid contain a manufacturer’s warranty, bidders must state the warranty terms in the space provided on the bid. Bids offered for merchandise when no warranty applies must clearly state: “NO WARRANTY COVERAGE”. Warranty information may be criteria in making this award. Failure of bidders to furnish this data may cause rejection of the complete bid as being non-responsive.

20. Disclosure Statement: The successful bidder will be required to file with Procurement Services a disclosure statement of relationship between contractors/grantees and employees/officials of the University. This form must be completed prior to issuance of the Purchase Order by the University.

20. State of Alabama Immigration Law: Pursuant to the State of Alabama Immigration Law, by signing this contract, the contracting parties affirm, for the duration of the agreement, that they will not violate federal immigration law or knowingly employ, hire for employment, or continue to employ an unauthorized alien within the State of Alabama.

Furthermore, a contracting party found to be in violation of this provision shall be deemed in breach of the agreement and shall be responsible for all damages resulting therefrom.

1. Restrictions On Communications with University Staff: From the issue date of this Solicitation until a Contractor is selected and a contract award is made, Bidders are not allowed to communicate about the subject of the bid with any University administrator faculty, staff, or members of the Board of Trustees except:

· The Procurement Services representative, any University Procurement Official representing the University administration, or others authorized in writing by the Procurement Office and

· University Representatives during Bidder presentations.

If violation of this provision occurs, the University reserves the right to reject the Bidder’s response to this Solicitation.

PRO REV. 6/12

Note: In order for an alternate bid to be considered, bidders must supply current catalogs or brochures, including pictorials and specifications.

F.O.B. Point

UAH DESTINATION

TERMS
WARRANTY

ESTIMATED DELIVERY

YOUR REFERENCE NO.*
QUOTATION EFFECTIVE UNTIL
BUSINESS CLASSIFICATION (see note below):
EMAIL ADDRESS:

* Your company reference number, if applicable with this bid quotation.

NOTE: Please indicate your company classification in the appropriate box above: Small Business (SB), a Small Disadvantaged Business (SD), a Black Small Disadvantaged Business (BD), a Woman-Owned Small Business (WB), a Woman-Owned Small Disadvantaged Business (WD), a Black Woman-Owned Small Disadvantaged Business (BW), a Large Business (LB), an Individual (IN), Educational (ED), Non-Profit (NP), a Labor Surplus Area Concern (LS), Disabled Veteran-Owned Small Business (DV), Veteran-Owned Small Business (VS), Historically Underutilized Business Zone (UZ), or a Governmental Agency (GV).

Certification Pursuant to Act No. 2006-557 Alabama Law (Section 41-4-116, Code of Alabama 1975) provides that every bid submitted and contract executed shall contain a certification that the vendor, contractor, and all of its affiliates that make sales for delivery into Alabama or leases for use in Alabama are registered, collecting, and remitting Alabama state and local sales, use, and/or lease tax on all taxable sales and leases into Alabama. By submitting this bid, the bidder is hereby certifying that they are in full compliance with Act No. 2006-557, they are not barred from bidding or entering into a contract pursuant to 41-4-116, and acknowledges that the awarding authority may declare the contract void if the certification is false.

________________________________________________________________________________________
COMPANY NAME (TYPE OR PRINT)TELEPHONE NUMBER
________________________________________________________________________________________
SIGNER’S NAME (TYPE OR PRINT)FAX NUMBER
________________________________________________________________________________________
SIGNATUREDATE

The University will not accept faxed bids.

Any product that fails to meet the specifications, performance requirements or compatibility requirements will be rejected and returned to the vendor at no cost to the University.

REV. 8/12

State of Alabama Immigration Law

If the successful bidder is located in Alabama or employs an individual or individuals within the State of Alabama, the successful bidder shall provide a copy of its Employment Eligibility Verification (E-Verify) company profile. To expedite the ordering process, this document may be submitted with the bid response.

If the successful bidder is not located in the State of Alabama and does not employ an individual or individuals within the State of Alabama, the successful bidder shall complete and return the Certification of Compliance form included with this Request for Price Quotation (E-Verify company profile is not required). To expedite the ordering process, this document may be submitted with the bid response.

If you are not currently enrolled in E-Verify, follow these instructions:

· Log onto www.uscis.gov/everify

· Click “Getting Started” for information about the program, requirements, and enrollment process.

· Click “Enroll in E-Verify” and begin enrollment process.

· When enrollment process is complete, click “Edit Company Profile” and print this one-page document.

· This one-page document must be submitted prior to a contract or purchase order being issued.

· For further assistance please consult the E-Verify Quick Reference Guide.

If you have previously enrolled in E-Verify, follow these instructions:

· Log onto www.uscis.gov/everify

· Click “Edit Company Profile” and print this one-page document.

· This one-page document must be submitted prior to a contract or purchase order being issued.

REV. 6/12

CERTIFICATION OF COMPLIANCE WITH THE

STATE OF ALABAMA IMMIGRATION LAW

The undersigned officer of _________________________________ (Company) certifies to the Board of Trustees of the University of Alabama that the Company is not located in Alabama and that the Company does not employ an individual or individuals within the State of Alabama.

SIGNATURE OF COMPANY OFFICER

PRINT COMPANY NAME

PRINT NAME OF COMPANY OFFICER

PRINT TITLE OF COMPANY OFFICER

DATE

REV. 6/12

VENDOR DISCLOSURE STATEMENT

In compliance with the policies of The Board of Trustees of the University of Alabama, The University of Alabama System Office, this University, and with Alabama state law, this Disclosure Statement shall be completed on a per contract basis for all contracts in excess of the statutory minimum provided in Section 41-16-82, Code of Alabama 1975 , including but not limited to proposals, bids, and contracts, including consulting/professional service contracts unless otherwise exempted (“Agreements”). The Board of Trustees of The University of Alabama reserves the right to refuse to enter into or to cancel, without penalty, any contract or agreement with any entity or individual who does not provide all of the information requested below, makes false or incomplete disclosures, or fails to supplement or amend such disclosures if circumstances change making the disclosures inaccurate or incomplete.

Definitions. For the purposes of this form, the following terms shall have the following meanings:

· “Agreement.” Any single agreement, contract, memorandum of understanding, or grant document under which goods or services are to be provided by You.

· “Entity.” The corporation, partnership, sole proprietorship, individual or business of any kind in whose name or on whose behalf the goods or services are being provided to the University.

· “Family Member.” Your spouse, dependent, an adult child and his or her spouse, a parent, a spouse’s parents, and a sibling and his or her spouse. The term "Dependent" shall include any person, regardless of his or her legal residence or domicile, who receives more than 50 percent of his or her support from the public official or employee or his or her spouse, or who resides with the public official or employee for more than 100 days during the reporting period.

· “Public Official.” Any person elected to public office, whether or not that person has taken office, by vote of the people at state, county, or municipal level of government or their instrumentalities, including governmental corporations, and any person appointed to take a position at the state, county, or municipal level of government or their instrumentalities, including governmental corporations.

· “Relationship.” Limited to familial or business in nature, or a personal relationship that the existence of which creates a Conflict of Interest or the appearance of a Conflict of Interest that would require disclosure under Board Rule 106.

· “UAS.” The Board of Trustees of The University of Alabama, and its constituent divisions including The University of Alabama System Office, The University of Alabama, The University of Alabama at Birmingham, and The University of Alabama in Huntsville.

· “You.” Includes (1) the individual(s) or representative(s) of the Entity who (a) solicited the Agreement or (b) are responsible for managing the account or relationship with the University, and their partners or co- owners; and (2) any member of the of foregoing individuals' immediate family (that You know to have a direct familial relationship with a UAS employee or official or family member of a UAS employee or official).

1. Name of Entity and Individual Completing this Form (may be completed by an authorized account manager/representative)

Entity Name:Individual Name:Title:Address Line 1:Address Line 2:
City, State, Zip:Telephone:

Email:

2. UAS Entity with which You propose an Agreement? (i.e. University, College, Department, etc.)

3. Describe the proposed Agreement:

Goods and services to be provided:Grant or proposal number (if applicable):Amount or anticipated amount:Term:
Is the proposed Agreement the result of a competitive or bid process?YesNo

4. Have "You" (See definition above) or the Entity supplying the goods or services previously provided goods and/ or services to UAS within the current or last fiscal year? _ Yes No

If yes, please provide the following information for each other agreement for such goods and/or services.

Entity Providing Goods or Services: Campus and Department: Type of Goods/Services: Amount Received:

Entity Providing Goods or Services: Campus and Department: Type of Goods/Services: Amount Received:

If you need to provide further details on goods or services provided to UAS within the current or last fiscal year, please attach an addendum to this Disclosure Statement.

5. Did the amount of goods and /or services identified in response to Question 4 total $1,000,000 or?

more? _ Yes No

6. a. Do You have a relationship with any UAS employee or Trustee who may directly or indirectly receive any benefit from the proposed Agreement, or whose family member or business may directly or indirectly benefit? _ Yes No

b. Do You have a relationship with any Public Official who may directly or indirectly receive any benefit from the proposed Agreement, or whose family member or business may directly or indirectly benefit? _ Yes _ No

If You answered “Yes” to questions 6.a. and/or b., please provide the following information for each UAS employee, Trustee, or Public Official with whom You have a Relationship.

Name of UAS employee, Trustee, or Public Official: Campus/department where employed or position held: Nature of relationship: Potential Benefit: Updated: September 2020

Name of UAS employee, Trustee, or Public Official: Campus/department where employed or position held: Nature of relationship: Potential Benefit:

If you need to provide further information regarding UAS employee(s) or Trustee(s), or Public Officials with whom You have a Relationship, and who may directly or indirectly benefit from this Agreement, please attach an addendum to this Disclosure Statement.

7. Have any paid consultants, lobbyists, and/or Public Official assisted in obtaining the proposed Agreement? Yes No If yes, please provide the following information for each consultant or lobbyist.

Name:

Address:

Name:

Address:

If you need to provide further information regarding paid consultants and/or lobbyists utilized to obtain the proposed Agreement, please attach an addendum to this Disclosure Statement.

8. List any current litigation or administrative action that has been filed within the last 3 years, either state or federal, related to public or higher education construction or finance that the contractor others associated with the firm may have against them.

9. Please provide any additional information requested by UAS in connection the Agreement. If you need to provide additional details or attachments, please attach an addendum to this Disclosure Statement.

By signing below, I certify under oath and penalty, as provided for in Section 41-16-86, Code of Alabama 1975, that all statements on or attached to this form are true and correct to the best of my knowledge. By proposing or entering into an Agreement with UAS, I certify I am authorized to complete this form on behalf of the Entity in whose name or on whose behalf goods or services are being provided, and I further certify no employee or official of UAS, nor any of their family members or any business with which they may be associated, will receive a benefit from this contract, except as has been disclosed, in writing herein. I will promptly disclose any Relationship which may arise in the future, or any existing Relationship which may become known to me, and update this statement to disclose the same.

Signature Date

Updated: September 2020 image2.jpeg image3.jpeg image1.jpeg

File details come from the government source that posted it. Updated .