REQUIRED_FORMS_-_AAs_11172022.pdf

Purchasing Division 100 N. Garfield, Room S348 Pasadena, CA 91101 Phone (626) 744-6755 https://www.cityofpasadena.net/finance/doing-business-with-the-city/

Vendor Questionnaire (Form AA-1)

Affidavit of Equal Opportunity Employment & Non-segregation By submitting this form you are declaring under penalty of perjury under the laws of the State of California and the laws of the

United States that the information is true and correct. Furthermore, you are certifying that your firm will adhere to equal opportunity employment practices to assure that applicants and employees are not discriminated against because of their race, religion, color, national origin, ancestry, disability, sex or age. And, your firm does not and will not maintain or provide for its employees any segregated facilities at any of its establishments, and that it does not and will not permit its employees to perform their services at any location, under its control, where segregated facilities are maintained. Additionally, no employees, consultants, or board members of your company or your subcontractors are current employees of the City of

Pasadena.

Name of Company:

Address:

State:

Contact Person:

Telephone:

E-mail Address:

City:

Zip:

DBA (if applicable):

Remit Address (if different):

Please state clearly and concisely the type(s) of goods and services your company would provide on this contract

Active City of Pasadena Business License Number:

Required For All Public Works: Pursuant to Division 2, Part 7, Chapter 1 (commencing with section 1720) of the California Labor Code, you must provide your Registration Number under the Department of Industrial Relations:

Small and Micro Business Preference Program: If certified by California Department of General Services as a small or micro business, please provide DGS Reference Number:

(Visit the Purchasing Division website for additional information):

The following section is OPTIONAL and is for statistical reporting purposes only. Ownership (please check all that apply):

☐African American

☐Asian

☐Armenian

☐Hispanic

☐Native

American

☐Disabled

☐Female https://www.cityofpasadena.net/finance/doing-business-with-the-city/

Pasadena, CA 91101

Phone (626) 744-6755

Project Workforce Utilization (Form AA-2) (OPTIONAL)

This form is to be included in all bid documents for projects involving labor or services valued at $25,000 or more.

Instructions: Please indicate the job titles/classifications to be used in the performance of this contract should it be awarded to your firm. Please indicate the number of employees in each job classification as well as the number of new hires, if any, as a result of this contract.

Name of Company: ___________________________________________

Project:___________________________________________

Job Titles/Classification Estimated number of existing staff to be employed in this classification if awarded the contract

Estimated number of new hires to be employed in this classification if awarded the contract

Are any current employees or potential new hires Pasadena residents? If so, how many?

Pasadena, CA 91101

Phone (626) 744-6755

Current Permanent Workforce Utilization (Form AA-3) (OPTIONAL)

Name of Company: ___________________________________________

Project: ____________________________________________________

Completion of this form is OPTIONAL. Any information supplied by Proposers is for reporting purposes only and will not be factored into the award of any contract.

Instructions: Please indicate the number of employees in each Job Classification belonging to the following groups.

White (not of Hispanic origin)

African-American (not of Hispanic origin)

Hispanic Asian/Pacific Islander

Native American

Armenian Male Female

CLASSIFICATION

Officials/Managers Professionals

Technicians

Office/Clerical

Skilled Craft

Workers

Operators (semi-skilled)

Laborers Service Workers

TOTAL