RFP Forms TBJH Track.pdf

FAMILIAL DISCLOSURE STATEMENT

(Complete one for each Respondent: Vendor, Subcontractor, Leasing Company)

All bidders must provide familial disclosure in compliance with MCL 380.1267 and attach this information to the bid proposal. The bid proposal will be accompanied by a sworn and notarized statement disclosing any familial relationship that exists between the owner or any employee of the bidder and any member of the Alpena Public Schools Board or Superintendent. The District will not accept a bid proposal that does not include this sworn and notarized disclosure statement.

The members of the Alpena Public School District Board are:

Michael Barnett, Steven Donajkowski, Ned Heath, Thomas Hilberg, Jackie Krawczak, Stacey Parr and Gordon Snow.

The Alpena Public School District Superintendent is: Dr. John VanWagoner.

☐ The following are the familial relationships:

Owner/Employee Name: Related to: Relationship:

1.

2.

3.

4.

Attach additional pages if necessary to disclose familial relationships.

☐ There is no familial relationship that exists: between the owner or any employee of the bidder and any member of the Alpena Public Schools District Board or the Alpena Public School District Superintendent.

Signature of Bidder Representative: _______________________________________________

Printed Name: ________________________________________________________________

Title: ________________________________________________________________________

Subscribed and sworn to before me this _____day of _______________, _______________

Notary Public, ___________County of _________

My Commission Expires _____/_____/_____

IRAN ECONOMIC SANCTIONS ACT CERTIFICATION

I am the _____________________________________________________________(title) of ____________________________________________________________________ (bidder) or I am bidding in my individual capacity ("Bidder"), with authority to submit a binding bid for the provision of ______________________________________ to Alpena Public Schools.

I have personal knowledge of the matters described in this Certification, and I am familiar with the Iran Economic Sanctions Act, MCL 129.311, et seq. ("Act"). I am fully aware that the school district will rely on my representations in evaluating bids.

I certify that Bidder is not an Iran-linked business, as that term is defined in the Act. I understand that submission of a false certification may result in contract termination, ineligibility to bid for three (3) years, and a civil penalty of $250,000 or twice the bid amount, whichever is greater, plus related investigation and legal costs.

Signature of Bidder Representative: _______________________________________________

Printed Name: ________________________________________________________________

Title: ________________________________________________________________________

Subscribed and sworn to before me this _____day of _______________, _______________

Notary Public, ___________County of _________

My Commission Expires _____/_____/_____

FORM OF STANDARD AGREEMENT(S)

Instructions to Bidders: Please attach examples of your standard agreements for the following documents, if they exist.

___________ Contract

___________ Maintenance or Service Agreements

___________ Warranties

REFERENCES – SERVICE PERFORMANCE

Instructions to Bidders: Please provide three service performance references. Please include Michigan School District(s) whenever possible.

Company Name and Contact Name: ___________________________________________

Address: _________________________________________________________________

Telephone: _________________________ Email: __________________________

Years you have served this Company: __________________________________________

Company Name and Contact Name: ___________________________________________

Address: _________________________________________________________________

Telephone: _________________________ Email: __________________________

Years you have served this Company: __________________________________________

Company Name and Contact Name: ___________________________________________

Address: _________________________________________________________________

Telephone: _________________________ Email: __________________________

Years you have served this Company: __________________________________________

FINANCIAL REFERENCES AND INFORMATION

Banking Reference:

Name and Contact Name: ___________________________________________________

Address: _________________________________________________________________

Telephone: _________________________ Email: __________________________

Number of Years: ___________________________________________________________

Vendor Reference:

Name and Contact Name: ___________________________________________________

Address: _________________________________________________________________

Number of Years: ________________________________________

Vendor Reference:

Name and Contact Name: ___________________________________________________

Address: _________________________________________________________________

Number of Years: ________________________________________

Bidder’s DUNS Number: _________________________________________________

Business Structure: Corporation ( ) Partnership ( ) Sole Proprietor ( ) Other ( )

Number of years in business as the company above: _______________________________

Largest single contract this company held: $______________________________________

Annual gross volumes for last three (3) years:

2017: __________________ 2016: ___________________ 2015: ___________________

Name of your Insurance Company: _____________________________________________

Insurance Limits: ___________________________________________________________

Please attach a copy of any current certificate(s) showing limits you normally carry.

Geographical area of operations for your firm: _____________________________________

Contracting Classification: General ( ) Sub ( ) Supplier ( ) Lessor ( )

Service provided by your firm:

Primary Services: ___________________________________________________

Other Services: _____________________________________________________

CONTRACTOR NOTIFICATION FORM

[In accordance with 40 CFR part 763.84(d)]

As required by the EPA AHERA standard, each school district is responsible for providing contractors with information regarding locations of known or assumed asbestos containing materials prior to entering a building under the school district’s jurisdiction.

Please complete this form and return it to Mr. Kurt Konieczny, Director of Facilities, Alpena Public Schools.

I, _________________________________, representing and having authority for ______________ (Bidder)

________________________________, hereby indicate and agree that a representative of the Alpena Public School District, has provided me information regarding the location of the inspection management plan for each building in the district.

These plans will provide me with specific information, location, and materials that are encountered during the course of activity involving the building(s) in question. I expressly agree that neither I nor any of my employees, agents, subcontractors, or other individuals or entities over whom I have any responsibility or control, will disturb asbestos containing materials as listed in the management plan for the building(s) in question. I further understand and agree that should I, my employees, agents, subcontractors, other individuals or entities over whom I have control, encounter any material suspected of containing asbestos, said materials shall not be disturbed without first notifying the office of the school district’s asbestos administrator, and receiving approval that such materials may be disturbed.

Signature Company

Title Address

Date Telephone

CONTRACTOR CERTIFICATION OF ASBESTOS-FREE PRODUCT INSTALLATION FORM

Alpena Public Schools

Contractor: _______________________________________

Address: _________________________________________

Brief Scope of Contracted Activities:

I,___________________________________, representing and having authority for

_______________________________________________, hereby certify that any and all (Company) products/materials which will be and/or have been installed or introduced into the above-mentioned project and building will be asbestos-free (or less than 1% asbestos by weight).

Signature Company

Title Address

Date Telephone

Attachment: Manufacturer's Specifications