REQUIRED_FORMS_-_AAs_-_SIG-LEGAL-STATUS_-_DECLARATION_OF_NONCOLUSION_08022024_v2.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.

Company Name:

Address:

City, State, Zip:

Contact Person:

Phone:

E-mail Address:

DBA (if applicable):

Remit Address (if different):

City, State, Zip:

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

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

Pasadena, CA 91101

Licenses and Certifications

Review the solicitation document to identify the required licenses or certifications, and list them on this form. This form is for quick reference only.

Company Name: __________________________________________________________

Project:__________________________________________________________________

Address: _______________________________________________________________

City, State, Zip: _______________________________________________________________

Phone: _____________________________

Email Address: _________________________________________________________

Agency, and Description Number

City of Pasadena (Pasadena Business License)

State of California, Department of Industrial Relations (Required For all Public Works: Pursuant to Division 2, Part 7, Chapter 1)

State of California, Department of General Services (Small and Micro Business Certification)

License/Certification Name

Issuing Organization Issue Date Status License or Certification Number

Pasadena, CA 91101

Project Workforce Utilization (Form AA-2)

This form is to be included in all bids 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.

Company Name: _____________________________________________________

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

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

Company Name: ___________________________________________

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

SIGNATURE PAGE AND LEGAL STATUS

Terms _______________________ 30 days

Delivery shall be no more than NINETY (90) days after receipt of City purchase order.

Firm__________________________________________________________________

Address _______________________________________________________________

City, State, Zip: _________________________________________________________

Phone _____________________________

Email Address_________________________________________________________

The undersigned certifies that he is an official legally authorized to bind his firm and to enter into a contract should the City accept this proposal.

Bid proposal by _______________________________________________________

(Name of Firm)

Legal status of bidder: Please check the appropriate box

__ Corporation State of Incorporation ___________________________

__ Partnership List Names ____________________________________

__ DBA State full name _______________________________________

__ Other Explain

Signature of Bidder __________________________________ Title_______________________

(Authorized Signature)

Address _______________________ City ___________State ____ Zip ________

Telephone No. _____________________________________________

Signed this _______________________day of _______________________, 20___

Non-Collusion Declaration

NON-COLLUSION DECLARATION TO BE EXECUTED BY COMPANY AND SUBMITTED WITH BID/PROPOSAL

The undersigned declares:

I am ___________________________________________________________________________, (Insert "Sole Owner", "Partner", "President, "Secretary", or other proper title) of_____________________________________________________________ (Insert name of Name of

Company], the party making the foregoing bid.

The party making the forgoing bid/proposal submitted herewith to the City of Pasadena declares:

That all statements of fact in such bid/proposal are true;

That such bid/proposal was not made in the interest of or on behalf of any undisclosed person, partnership, company, association, organization or corporation;

That such bid/proposal is genuine and not collusive or sham;

That said Proposer has not, directly or indirectly by agreement, communication or conference with anyone attempted to induce action prejudicial to the interest of the City of Pasadena, or of any other Proposer or anyone else interested in the proposed contract; and further

That prior to the public opening and reading of bids/proposals, said Proposer:

a. Did not directly or indirectly, induce or solicit anyone else to submit a false or sham bid/proposal;

b. Did not directly or indirectly, collude, conspire, connive or agree with anyone else that said Proposer or anyone else would submit a false or sham bid/proposal, or that anyone should refrain from bidding or withdraw his or her bid/proposal;

c. Did not, in any manner, directly or indirectly, sought by agreement, communication, or conference with anyone to raise or fix the bid/proposal price of said Proposer or of anyone else, or to raise or fix any overhead, profit, or cost element of the bid/proposal price, or of that of anyone else;

d. Did not, directly or indirectly, submit his or her bid/proposal price or any breakdown thereof, or the contents thereof, or divulge information or data relative thereto, to any corporation, partnership, company, association, organization, bid depository, or to any member or agent, or to any individual or group of individuals thereof to effectuate a collusive or sham bid, except the City of Pasadena, and has not paid, and will not pay, any person or entity for such purpose or to any person or persons who have a partnership or other financial interest with said Proposer in his or her business.

Any person executing this declaration on behalf of a Proposer that is a corporation, partnership, joint venture, limited liability company, limited liability partnership, or any other entity, hereby represents that he or she has full power to execute, and does execute, this declaration on behalf of the Proposer.

I certify under penalty of perjury of the laws of the State of California that the above information is correct.

Signed: ______________________________________ Title: ________________________________

Typed Name: _________________________________

Date: ____________________________________