RFP 27-0004 Backflow Prevention Final.docx
DOCX document 121 KB Posted
- Solicitation number
- RFP-123606
- Issued by
- Carroll County, Virginia
About this file
This is a Request for Proposal (RFP) issued by the City of Galax, Virginia, for comprehensive cross-connection control and backflow prevention program services. The City seeks qualified firms to establish a one-year initial contract with four successive one-year renewal options to provide inspection, survey, review, and maintenance services for approximately 485 commercial and industrial properties within Galax. Services include performing utility cross-connection control program reviews, conducting in-person surveys (initial, re-surveys, and compliance surveys) of potable water distribution systems, documenting testable and non-testable backflow prevention devices, coordinating customer notifications, providing full-time phone support during normal business hours, managing testing of backflow prevention assemblies, generating compliance notifications, conducting compliance surveys, and delivering quarterly and annual comprehensive management reports to the City. The proposal submission deadline is July 17, 2026, at 2:00 PM, with proposals submitted to Rita Moxley, Procurement Specialist, at the City of Galax offices. The City will select one or more firms using the Competitive Negotiation procedure in accordance with the Virginia Public Procurement Act.
Pricing proposals must include annual totals with separate optional pricing for additional Fats, Oils, and Grease (F.O.G.) testing services. The selection committee will evaluate proposals based on key personnel qualifications and experience, understanding of scope of services, cost-effectiveness, ability to perform required services, and reference source comments and past performance on similar projects, with price as a consideration but not the sole determining factor. Proposals must include professional experience and qualifications, a listing of subconsultants and subcontractors, proposed pricing and rates, three professional references, and availability on an as-needed basis. The City requires contractors to maintain Commercial General Liability Insurance of not less than $2,000,000 per occurrence and Professional Liability Insurance of not less than $2,000,000 per occurrence, with the City named as an additional insured. All proposals are public records under Virginia's Freedom of Information Act, and the City reserves the right to accept or reject any or all proposals.
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| City_of_Galax_RFP27-0004_Public_Notice_Condensed.pdf |
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Text version
CITY OF GALAX, VIRGINIA
REQUEST FOR PROPOSAL (RFP) 27-0004
FOR
CROSS CONNECTION CONTROL & BACKFLOW PREVENTION PROGRAM SERVICES
June 30, 2026 The City of Galax (the “City”) is seeking the services of qualified firms (Firms) to establish a one-year contract with four successive one-year renewal options for all inspection, survey, review, and maintenance services associated with a Cross Connection Control & Backflow Prevention Program involving approximately 485 commercial and Industrial properties located within the City. The City will select one or more Firms to provide the services requested using the Competitive Negotiation procedure. The City will receive proposals until July 17, 2026 at 2:00 PM.
Submittal of a proposal indicates acceptance of the conditions contained in the RFP. All proposals are public records to the extent required by the Virginia Freedom of Information Act (FOIA). The City of Galax reserves the right to accept or reject any or all proposals.
I. SCOPE OF SERVICES:
The City of Galax reserves the right to alter the Scope of Services for this project as deemed in the best interest of the City. The successful Firm shall be required to perform backflow prevention maintenance and inspections; including but not limited to the following tasks:
1) Perform a Utility Cross Connection Control Program review including the following:
a. Review of all relevant state and local regulations for the complete and satisfactory performance of all services in accordance with state and local code requirements and the Virginia Department of Health, Office of Drinking Water Cross Connection Control Regulations.
b. Review of City Code Chapter 44 – Cross Connections; Backflow Prevention and recommend any required changes in the ordinance necessary for compliance with the Virginia Department of Health, Office of Drinking Water Cross Connection Control Regulations.
c. Review timeliness for program notices (Survey Notice, Compliance Notice, Non-Compliance Notices 1-2, Penalty Notices)
d. Prioritize surveys and establish facility survey schedule
e. Obtain updated facility listing and address information
f. Review program reporting procedures
g. Review high hazard and large industrial facility survey/containment procedures
h. Review procedures and protocol for addressing specific hazards.
2) Complete in-person surveys (initial surveys, re-surveys, compliance surveys) using the containment review approach supported by Virginia Department of Health, Office of Drinking Water unless otherwise specified. All surveys will be of the entire potable water distribution system. New surveys shall include first time survey of new accounts not previously included in the cross-connection programs. Re-surveys shall include the periodic (every five years) survey of accounts. Compliance surveys shall consist of surveys at accounts of corrective actions completed to confirm correction of previously noticed non-compliance conditions.
3) Provide proposed survey plan to the City for review prior to commencing surveys. The proposed plan should provide priority to high hazard customer accounts.
4) Coordinate and notify customers of inspection/testing requirements and surveys and/or re-surveys in writing.
5) All testable & non-testable backflow prevention devices, program requirements and relevant code violations will be documented during the on-site surveys.
6) All existing backflow prevention devices (i.e. testable & non-testable) must be inspected, inventoried and documented. Records shall be maintained of the account Owner’s device test results. All testable devices are required to be tested annually by the account owner’s agent.
7) Generate all program notifications for users failing initial surveys and/or re-surveys informing them of installation requirements and/or testing requirements.
8) Perform compliance surveys for each non-compliant location upon notification of completion of compliance requirements. All compliance surveys will be scheduled and completed as required.
9) Provide full-time phone support for customer questions with a trained customer service agent. The Contractor’s phone will be staffed during normal business hours, Monday through Friday. An automatic message service will be provided for after-hour calls.
10) Coordinate and manage the testing of all testable backflow prevention assemblies in accordance with VA VDH requirements. Services include testing notification, requirements, receipt of executed test report, and maintenance of all testing data.
11) Provide comprehensive management reports to the City on a quarterly and annual basis and obtain any required approval of the annual report from the VA VDH on the City’s behalf.
12) Comprehensive annual reports shall include a program summary, copy of the annual report, a detailed listing of all survey locations, and individual listing of those facilities in, or not in, compliance, surveys completed, sites never surveyed, and notifications sent.
13) Provide progress meetings with the City’s designated representative to discuss program status and specific recommendations as requested. Coordinate all scheduling of services with the City staff.
14) Assist the City with a community-wide public relations program, including multiple methods of communicating general knowledge and awareness (i.e., educational cross-connection control brochures and website resources)
15) The contractor shall not be required to enter confined spaces.
16) In addition to the services requested in this section of the RFP, if the Firm offers F.O.G. testing, separate pricing details are requested from the Firm for this service in the proposal. Please note that these additional services are optional and will be considered based on need and budget availability.
II. PROPOSAL CONTENT REQUIREMENTS:
Proposals shall include, but are not limited to, the following content:
· Professional experience and qualifications. - - - - - -
· A listing of subconsultants and subcontractors that may be used to accomplish tasks or services under this Request for Proposals.
· Proposed pricing/rates with annual totals.
· Three (3) professional references.
· Availability of the Firm on an as-needed basis.
· Other items the Offeror may want to include.
In order to be considered for selection, offerors must submit a complete response to this RFP. One original and three (2) copies of sealed proposals or one electronic copy (eVA Procurement System) are due by July 17, 2026 at 2:00 PM., prevailing time, and marked in the upper left-hand corner “Backflow Prevention Maintenance & Inspections”. Only the eVA electronic procurement system will be used for electronic submittals. The selection process will be in accordance with the Virginia Code Section 2.2 – 4302 (A) (4) for the procurement of professional services. Minority and/or female-owned businesses or firms are encouraged to apply. The City of Galax is an Equal Opportunity Employer.
Proposals shall be delivered to:
Rita Moxley, Procurement Specialist 111 East Grayson Street Galax, VA 24333
III. INQUIRIES
Questions and inquiries from offerors must be directed to Rita Moxley, Procurement Specialist, at 276-236-2131 or rmoxley@galaxva.com and must be received by Thursday, July 16, 2026 at 2:00 PM. All inquires that affect the nature of the proposed contract or proposal contents will be responded to in the form of an Addendum. It is the responsibility of the offeror to check for updates prior to submission and ensure they the current, complete version of the RFP documents, including any addenda, before submitting a proposal.
IV. EVALUATION AND AWARD CRITERIA:
The City of Galax reserves the right to accept or reject any or all proposals received as a result of this request; to negotiate with any qualified firm or to modify or cancel in part or in its entirety the Request for Proposal if it is in the best interest of the City to do so. This Request for Proposal does not commit the City of Galax to award a contract, to pay any costs incurred in the preparation of a proposal for this request, or to procure or contract for services.
The City will select a Firm to provide the services requested using the Competitive Negotiation procedure for goods and Nonprofessional Services as outlined in the Virginia Public Procurement Act.
A selection committee shall evaluate and rank each proposal based on the established selection criteria included within this RFP. Final ranking of the individual Firms shall be based on a majority decision; then two or more Firms deemed to be fully qualified and best suited among those submitting proposals, on the basis of the factors stated in this Request for Proposal. Negotiations shall then be conducted with each of the offerors so selected. The offerors shall state any exception to any liability provisions contained in the Request for Proposal in writing at the beginning of negotiations, and such exceptions shall be considered during negotiation. Price shall be considered but will not be the sole or primary determining factor. After negotiations have been conducted with each offeror selected, the public body shall select the offeror which, in its opinion, has made the best proposal and provides the best value, and shall award the contract to that offeror.
The City of Galax prohibits discrimination and requires compliance with state and federal immigration laws as defined under the Code of Virginia Chapter 43 Virginia Public Procurement Act. The City is an equal opportunity employer and encourages participation of small businesses, minority owned businesses, women owned businesses and service disabled veteran owned businesses in all procurement activities.
The City of Galax does not discriminate against an offeror because of race, religion, color, sex, national origin, age, disability, or any other basis prohibited by state law relating to discrimination in employment.
Any offeror who desires to protest the award of a contract shall submit such protest in writing to the City of Galax no later than ten (10) days after the announcement of the award. Public announcement of the award shall be posted on the City of Galax internet website: www.galaxva.com. Evaluation criteria will generally involve relevant experience, specific expertise, performance references on previous projects and analysis of all proposal content. The following criteria will be considered in evaluating the proposals:
· Qualification and experience of key personnel and specific staff to be tasked with providing services under the Term Contract.
· Understanding of the Scope of Services.
· Evidence of ability to evaluate and provide cost effective solutions for services described in the Scope of Services section of this RFP.
· Evidence of ability to perform required services as described in the Scope of Services section.
· Reference source comments and past record of performance on similar projects.
ATTACHMENT A
GENERAL TERMS AND CONDITIONS
A. ANTI-DISCRIMINATION: By submitting a proposal, the offeror represents and warrants to City of Galax, Virginia that it will conform to the provisions of the Federal Civil Rights Act of 1964, as amended, the Virginia Fair Employment Contracting Act of 1975, as amended, where applicable, the Virginians with Disabilities Act, the Americans With Disabilities Act, Section 2.2-4311 of the Virginia Public Procurement Act (VPPA), and all other applicable federal, state and local anti-discrimination laws, codes, rules, and regulations. Without limiting the foregoing, during the performance of this contract, the offeror agrees as follows:
1. The offeror will not discriminate against any employee or applicant for employment because of race, religion, color, sex, national origin, age, disability, or any other basis prohibited by state or federal law relating to discrimination in employment, except where there is a bona fide occupational qualification reasonably necessary to the normal operation of the offeror. The offeror agrees to post in conspicuous places, available to employees, notices setting forth the provisions of this nondiscrimination clause.
2. The offeror, in all solicitations or advertisements for employees placed by or on behalf of the offeror, will state that such offeror is an equal opportunity employer.
3. Notices, advertisements and solicitations placed in accordance with federal law, rule or regulation shall be deemed sufficient for the purpose of meeting these requirements.
4. The offeror will include the provisions of the above 1, 2 and 3 in every subcontractor or purchase order over $10,000 in connection with this RFP, so that the provisions will be binding upon each subcontractor or vendor.
B. DRUG-FREE WORKPLACE: During the performance of the contract, the offeror agrees to (i) comply with the drug-free workplace provisions of Virginia Code 2.2-4312; (ii) provide a drug-free workplace for the offeror’s employees; (iii) post in conspicuous places, available to employees, a statement notifying employees that the unlawful manufacture, sale, distribution, dispensation, possession, or use of a controlled substance is prohibited in the offeror’s workplace and specifying the actions that will be taken against employees for violations of such prohibition; (iv) state in all advertisements or solicitations for employees that the offeror maintains a drug-free workplace; and (v) include the provisions of the foregoing clauses in every subcontract or purchase order of over $10,000 in connection with this RFP, so that the provisions will be binding upon each subcontractor or vendor.
C. IMMIGRATION REFORM AND CONTROL ACT OF 1986: By submitting its proposal, the offeror represents and warrants that it does not and will not during the performance of this contract employ illegal alien workers or otherwise violate the provisions of the federal Immigration Reform and Control Act of 1986.
D. APPLICABLE LAWS AND COURTS: This solicitation and any resulting contract shall be governed in all respects by the laws of the Commonwealth of Virginia and any litigation with respect thereto shall be brought in a court of appropriate jurisdiction in the City of Galax, Virginia. The offeror shall comply with all applicable federal, state and local laws, codes, rules and regulations.
E. ETHICS IN PUBLIC CONTRACTING: By submitting their proposals, the offeror represents and warrants that its proposal is made without collusion or fraud and that it has not offered or received any kickbacks or inducements from any other offeror, supplier, or subcontractor in connection with their proposal, and that it has not conferred on any public employee having official responsibility for this procurement transaction any payment, loan, subscription, advance, deposit of money, services or anything of more than nominal value, present or promised, unless consideration of substantially equal or greater value was exchanged. Furthermore, the provisions, requirements, and prohibitions contained in Sections 2.2-4367 through 2.2-4377 of the Virginia Code, pertaining to bidders, offerors, contracts, and subcontractors, are applicable to this RFP and any resulting contract, as are the provisions, requirements, and prohibitions contained in Sections 2.2-3100 through 2.2-3131 of the Virginia Code.
F. QUALIFICATIONS OF OFFEROR: The City may make such reasonable investigations as deemed proper and necessary to determine the ability of the offeror to provide the services/furnish the goods as required under this RFP, and the offeror shall furnish to the City all such information and data for this purpose as may be requested. The City reserves the right to inspect the offeror’s physical facilities prior to award to satisfy questions regarding the offeror’s capabilities. The City further reserves the right to reject any proposal if the evidence submitted by, or investigations of, such offeror fails to satisfy The City that such offeror is properly qualified to carry out the obligations of the contract and to provide the services and/or furnish the goods contemplated therein.
G. DEBARMENT STATUS: By submitting its proposal, the offeror represents and warrants that it is not currently debarred by the Commonwealth of Virginia, or any city, county, town or political subdivision therein, from submitting bids or proposals on contracts for the type of goods and/or services covered by this solicitation, nor is it an agent of any person or entity that is currently so debarred.
H. NONDISCRIMINATION TOWARDS OFFERORS: A bidder, offeror or contractor shall not be discriminated against in the solicitation or award of this contract because of race, religion, color, sex, sexual orientation, gender identity, national origin, age, disability, status as a service disabled veteran, or any other basis prohibited by state law relating to discrimination in employment or because the bidder or offeror employs ex-offenders unless The City has made a written determination that employing ex- offenders on the specific contract is not in its best interest. THE CITY DOES NOT DISCRIMINATE AGAINST FAITH-BASED ORGANIZATIONS.
I. SCC REGISTRATION: Pursuant to Virginia Code § 2.2-4311.2, the offeror must be registered with the State Corporation Commission if so required by Title 13.1 or Title 50 of the Virginia Code or otherwise required by law.
J. MINORITY CONTRACTING: It is the policy of the City to maximize participation by minority and women owned businesses, small businesses, and service-disabled veteran businesses in contracting opportunities.
K. AVAILABILITY OF FUNDS: It is understood and agreed by the offeror that the City shall be bound only to the extent of the funds available or which may hereafter become available for the purpose of the Contract.
L. DEFAULT: In case of failure to deliver goods or services in accordance with the contract terms and conditions or other breach of any resulting contract by the offeror, the City may terminate the contract and/or procure the goods and services from other sources and hold the offeror responsible for any resulting additional purchase and administrative costs. These remedies shall be in addition to any other remedies which the City may have under the contract, at law, or in equity.
M. CONTRACTUAL CLAIMS: The procedure for reviewing and resolving contractual claims and resolving contractual disputes shall be the procedure set forth in Virginia Code § 2.2-4363.C.
N. WARRANTIES: Any services furnished by the contractor under the contract shall be covered by the most favorable warranties provided by the contractor to any customer; the rights and remedies hereby provided are in addition to any and do not limit those otherwise available to the City. The contractor agrees that if such warranties are in any respect breached, the contractor will pay to the City the full contract price agreed to by the City to be paid for the services furnished under the bid or proposal.
O. MODIFICATIONS, ADDITIONS, OR CHANGES: Modifications, additions, or changes to these terms and conditions may not be made except in writing and agreed to by the City; however, no fixed priced contract may be increased by more than twenty-five (25) percent of the amount of the contract or $50,000 whichever is greater without the approval of the City.
P. ASSIGNMENT: The contract may not be assigned, sublet, or transferred without the written consent of the City.
Q. OWNERSHIP OF DOCUMENTS: Any reports, photographs, negatives, or other documents prepared by the contractor in the performance or obligations under any resulting contract shall be remitted to the City by the contractor upon completion, termination, or cancellation of the contract. The contractor shall not use, willingly allow, or cause to have such materials used for any purpose other than the performance of the contractor’s obligations under the contract without the prior written consent of the City. The City shall own the intellectual property rights to all materials produced under any resulting contract. All data submitted to the City deemed to be confidential or proprietary by the contractor, whether as a part of the contractor’s proposal or as part of the contractor’s work product under a contract with the City shall be appropriately marked for protection in accordance with the Virginia Freedom of Information Act and the Virginia Public Procurement Act.
R. ENVIORNMENTAL MANAGEMENT: The Contractor will be responsible for complying with all federal, state, and local environmental regulations relating to transportation, handling storage, spillage and any other aspect of providing services specified herein, as applicable. If the City should have to defend any enforcement action against it relating to the services provided by the Contractor under any contract, the Contractor shall indemnify and hold harmless the City for any such actions, including reimbursing the City for all costs associated with defending such actions, attorney fees and costs, and shall correct without cost to the City any defects or deficiencies found that are directly attributable to the Contractor.
S. NO WAIVER: Any failure of the City to demand rigid adherence to one or more of the provisions in the contract, on one or more occasions, shall not be construed as a waiver nor deprive the City of the right to insist upon strict compliance with the terms of the contract.
T. INSURANCE REQUIREMENTS:
Contractor's Liability Insurance and Indemnification
1) The Contractor shall not commence work under this contract until Contractor has obtained all the insurance required under this paragraph and such insurance has been approved by the City, nor shall the Contractor allow any Subcontractor to commence work on its Subcontract until the insurance required of the Subcontractor has been so obtained and approved.
2) All insurance policies shall be issued by companies authorized to conduct such business under the laws of the State of Virginia and be acceptable to the City.
3) The status of the Contractor in the work to be performed by it under the Contract shall be that of an independent Contractor. As such, Contractor shall exercise due care to safeguard against any and all damage, loss or injury to persons or property that may arise, or be incurred, in or during the conduct or progress of said Work and which arises out of the Work.
4) The Contractor shall assume all responsibility for risks or casualties of every description, for any and all damage, loss or injury, to persons or property arising out of the nature of the work; negligence or failure of its employees and Subcontractors to comply with the Contract Documents; arising from action of the elements or from any unforeseen or unusual difficulty. The Contractor shall protect, defend, indemnify and save harmless the City, and all of its officers, agents and employees; and the Engineer and/or Engineer, as named on the plans and specifications, and its partners, agents and employees from all claims, demands and liabilities of any kind whatsoever in connection with work resulting from any acts of omission or commission chargeable to the Contractor, its Subcontractors and/or their respective duly authorized servants and/or employees. The Contractor agrees that the foregoing indemnification clause shall be insured under its Commercial General Liability policy, which must be endorsed to include Contractual Liability. If required by the City, the Contractor shall produce evidence of settlement by any such action before payment will be made by the City.
Compensation Insurance The Contractor shall procure and shall maintain during the life of this Contract Worker's Compensation Insurance as required by the State of Virginia for all of its employees to be engaged in such work at the site of the project under this Contract and in case any such work is sublet, the Contractor shall require the Subcontractor similarly to provide Worker's Compensation Insurance for all of the latter's employees to be engaged in such work unless such employees are covered by the protection afforded by the Contractor's Worker's Compensation Insurance. In case any class of employees engaged in hazardous work on the project under this Contract is not protected under Worker's Compensation Statute, the Contractor shall provide and shall cause such Subcontractor to provide adequate employer's liability insurance for the protection of such of its employees as are not otherwise protected. The insurance referred to in this paragraph contain provisions waiving underwriters' rights of subrogation against the City.
Contractors Commercial General Liability Insurance
1. The Contractor's Commercial General Liability (CGL) shall be in an amount acceptable to the City but not less than $2,000,000.00 per occurrence and $2,000,000.00 general aggregate per project. The City must be named as an additional named insured. The coverage must include:
• Commercial Form
• Premises/Operations
• Underground, Explosions, and Collapse Hazard (if excavation, blasting, tunneling, demolition or rebuilding of any structural support of a building is involved or explosion hazard exists).
• Products/Completed Operations
• Contractual Liability Insurance
• Independent Contractors (if any part of the Work is to be subcontracted)
• Broad Form Property Damage
• Personal Injury
• Cross-Liability Coverage
2. Contractor shall maintain products/completed operations coverage with a combined single limit no less than $2,000,000.00 per occurrence of bodily injury/property damage for a period of at least twelve (12) months following final acceptance of Contractor's work by City.
3. The insurance required herein and approval of Contractor's insurance by the City shall not relieve or decrease the liability of the Contractor hereunder.
Subcontractor's Commercial General Liability Insurance The Contractor shall either (1) require each of its Subcontractors to procure and to maintain during the life of its subcontract, Commercial General Liability Insurance of the type and in the amounts specified in Sub-Paragraph c hereof, or; (2) to insure the activities of its Subcontractors in its policy, as specified in Sub-Paragraph c hereof.
Professional Liability Insurance The Contractor’s Professional Liability coverage shall be in an amount acceptable to the City but not less than $2,000,000.00 per occurrence and $2,000,000.00 general aggregate per project. The City must be named as an additional named insured.
Scope of Insurance and Special Hazards The insurance required under Sub-Paragraphs c and d hereof is a minimum to provide adequate protection for the Contractor and its Subcontractors, respectively, against damage claims which may arise from operations under this Contract, whether such operation be by the insured or by anyone directly or indirectly employed by the insured and, also against any of the special hazards which may be encountered in the performance of this Contract.
Proof of Carriage of Insurance
1. The Contractor shall furnish the City annually with a certificate of insurance with, where appropriate, permission of the City to occupy, showing the type, amount, class of operations covered, effective dates and dates of expiration of policies. The certificate must indicate that the City is included as an additional named insured. Such certificates shall also contain substantially the following statement: "The insurance covered by this certificate will not be cancelled or materially altered, except after thirty (30) days written notice has been received by the City.
2. Contractor shall provide copies of any or all required insurance policies on request of City.
Renewal Requirements If any of the property or casualty insurance requirements are not complied with at their renewal dates, payments to the Contractor will be withheld until those requirements have been met or, at the option of the City, the City may pay the renewal premium and withhold such payment from any monies due the Contractor.
ATTACHMENT B: CERTIFICATIONS
ANTI-COLLUSION STATEMENT
In the preparation and submission of this proposal, we did not either directly or indirectly enter into any combination or arrangement with any person, firm or corporation, or enter into any agreement, participate in any collusion, or otherwise take any action in the restraint of free competition in violation of the Sherman Anti-Trust Act, 15 USCS Sections 1 et seq., or the Conspiracy to Rig Bids to Government Statutes, Virginia Code Sections 59.1-69.6 through 59.1.69.9. The undersigned hereby certifies that this proposal, any ensuing contract, or any claims resulting from either, is not the result of, or affected by, any act of collusion with, or any act of, another person or persons, firm or corporation engaged in the same line of business or commerce; and, that no person acting for, or employed by, Galax City Council or the City of Galax has an interest in, or is concerned with, this proposal; and, that no person or persons, firm or corporation, other than the undersigned, have or are interested in this bid.
Date:
CERTIFICATION OF INTEREST & RELATIONSHIPS
WITH THE Galax City Council OF GALAX CITY, VIRGINIA, GALAX CITY GOVERNMENT, AND
GALAX CITY EMPLOYEES
Offeror hereby certifies that neither Offeror, nor any of Offeror’s officers, directors, or executive employees maintain a financial or familial relationship with any person acting for, or employed by, The City of Galax or the Galax City Council of Galax City, Virginia. To the extent that such relationships exist, Offeror shall reveal the relationship below by describing the nature of the relationship and identifying the person with whom such relationship exists.
□Neither Offeror nor any of its officers, directors, or executive employees maintain a financial or familial relationship with any person acting for, or employed by, The City of Galax, or the City Council of Galax City, Virginia.
□The following individuals currently maintain a financial relationship with Offeror. City of Galax Employee’s Name:
Position with the City of Galax:
Nature of Relationship: __________________________________________________________ □The following individuals currently maintain a familial relationship with Offeror.
City of Galax Employee’s Name: __________________________________________________ Position with the City of Galax: ______________________________________________________ Nature of Relationship: __________________________________________________________ Date: Signature:
DEBARMENT STATEMENT
I certify that the offeror is not currently debarred or otherwise declared ineligible by any public agency from bidding for furnishing materials, supplies or services. I further certify that no principal, officer or director of the offeror has been employed by or associated with any firm which is currently debarred or otherwise declared ineligible by any public agency from bidding for furnishing materials, supplies or services.
I certify that the offeror has never been debarred, or otherwise declared ineligible by any public agency from bidding or furnishing materials, supplies or services. I further certify that no principal, officer or director of the offeror has ever been employed by or associated with any firm which has ever been debarred or otherwise declared ineligible by any public agency from bidding for furnishing materials, supplies or services.
Offeror Date image1.png image2.emf
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