PROB26-PROB-6362 - ATTACHMENT K - Local Vendor Preference Self-Certification.pdf

TO BE CERTIFIED AS A LOCAL VENDOR, eligible for Local Vendor Preference (any vendor, contractor or consultant, hereafter “vendor” ) I certify under penalty of perjury that����������������������������������������� meets all of the following requirements:

• The main office (headquarters) or a major regional office is located within the boundaries of San Bernardino County;

• Twenty-five percent (25%) of full-time management employees and twenty-five percent (25%) of full-time regular employees work from locations in the County;

• Employ at least one full-time or two part-time employees with primary residence in the County;

• “Point of sale” for purposes of reporting sales tax to the State Board of Equalization (if applicable) is within the boundaries of the County and payment of any local share of sales tax goes to the County or a city within the County. ( If the local business has more than one sales office in the State of California, the office located in the County shall be the point of sale for sales tax calculation);

• Not delinquent in any taxes or other payments to the County;

• Possess a valid and verifiable business license in��������������������������������������������������������� (if required);

• Have been open and established since _________________ ;

• Have had on-going business activity in the field of ___________________________________________ since_________________ (which is at least six months prior to the issuance of the solicitation);

• Have not, within five years prior to the date this form is signed, admitted guilt or been found guilty by any court or state or federal regulatory enforcement agency of violation of any criminal law or any law or regulation regarding fraud and not federally debarred; and

• Not suspended or debarred from participation in the County, in the scope of work that is the subject of the solicitation.

FURTHER, I acknowledge by initialing the following boxes that I understand:

–If any time after being certified as a local vendor, a change in status occurs rendering a vendor no longer eligible for such status, the vendor must notify the Purchasing Agent prior to responding to a solicitation or accepting an award.

Self certification is good for a period of five years, then must be renewed.

–False certifications shall be immediate grounds for rejection of any proposal or bid or if the proposal or bid is awarded, grounds for voiding the proposal or bid, terminating any agreement, and seeking damages thereto. Failure to certify the above information shall result in the proposal or bid being considered by the County without any adjustment for a local vendor.

–Self-certification provided by the vendor requesting a local preference shall be submitted to the Purchasing Agent under penalty of perjury. No person or business shall make a false representation to a County official or employee for the purpose of influencing the certification or denial of certification of any local vendor.

–Any vendor that falsely obtains certification shall be ineligible to transact business with the County for not less than one year and not more than three years, at the discretion of the Purchasing Agent. This penalty shall also apply to any vendor that previously obtained proper certification and, because of a change in its status would no longer be eligible for certification, and fails to notify the County of this information prior to responding to a solicitation or accepting an award.

Purchasing

LOCAL VENDOR PREFERENCE

SELF-CERTIFICATION

Vendor Legal Name______________________________________

Vendor Representative __________________________________

Vendor Address_________________________________________

City, State, Zip__________________________________________

Phone__________________________________________________

Email___________________________________________________

Federal Tax ID #___________________________________________

Reviewed By:

Location(s)

Date

DateNature of Business

I am an authorized representative of_____________________________________________and can legally bind the company.

Date Name Position