RFP Required Forms.pdf

TECHNICAL PROPOSAL COVER PAGE

TITLE:

TO: HOWARD COUNTY OFFICE OF PROCUREMENT AND CONTRACT ADMINISTRATION

6751 Columbia Gateway Drive, Suite 226

Columbia, MD 21046

The undersigned agrees to furnish and deliver the above goods and/or services in accordance with the specifications issued for same, and subject to all terms, conditions, and requirements in the solicitation, and in the various bid documents:

COMPANY NAME:

FEDERAL TAX IDENTIFICATION NO./SOCIAL SECURITY NO.:

ADDRESS:

Street City State Zip

TELEPHONE: FAX:

EMAIL ADDRESS:

REPRESENTATIVE’S NAME:

Provide the name and title of the person with legal authority to sign on behalf of the Contractor. If the title of the individual is not “President” or “Vice President”, provide verification of the signatory authority with your submittal.

NAME OF COMPANY SIGNATORY (Printed):

TITLE OF COMPANY SIGNATORY (Printed):

Howard County prefers to email Purchase Orders when possible, please provide an EMAIL ADDRESS FOR

RECEIPT OF PURCHASE ORDERS:

Is the company a Minority-, Women-, or Disabled-Owned Business Enterprise? YES NO

If yes, indicate the type of minority ownership:

African American Asian American Disabled Eskimo

Female Hispanic Native American

Is the company certified? If yes, indicate the certification(s) held:

Howard County Government MD Dept. of Transportation City of Baltimore Other

Certification Number(s) and Expiration Date(s):

Does the company have a written non-discrimination policy (i.e.: race, creed, religion, handicap, color, sex, national origin, age, occupation, marital status, political opinion, sexual orientation, gender identity/expression, personal appearance, familial status, source of income)? YES NO (The County reserves the right to request such documentation, if desired, at a later date.)

Delivery Time After Receipt of Order:

Delivery Terms: F.O.B. Destination, Inside Delivery.

The company will accept Visa procurement cards: YES NO (Contractors are not permitted to charge the County any additional fees over and above their bid prices to process payments on procurements cards.)

HOWARD COUNTY, MARYLAND

Office of Procurement and Contract Administration

AFFIDAVIT

Must be completed, signed by an officer of the company (President, CEO, Vice President, etc.)

Contractor

Address

I, , the undersigned, of the above named

(Print Signer's Name) (Title)

Contractor does declare and affirm this day of , , that I hold the aforementioned office

(Month) (Year) in the above named Contractor and I affirm the following:

AFFIDAVIT I

The Contractor, his Agent, servants and/or employees, have not in any way colluded with anyone for and on behalf of the Contractor or themselves, to obtain information that would give the Contractor an unfair advantage over others, nor have they colluded with anyone for and on behalf of the Contractor, or themselves, to gain any favoritism in the award of the contract herein.

AFFIDAVIT II

No officer or employee of Howard County, whether elected or appointed, has in any manner whatsoever, any interest in or has received prior hereto or will receive subsequent hereto any benefit, monetary or material, or consideration from the profits or emoluments of this contract, job, work or service for the County, and that no officer or employee has accepted or received or will receive in the future a service or thing of value, directly or indirectly, upon more favorable terms than those granted to the public generally, nor has any such officer or employee of the County received or will receive, directly or indirectly, any part of any fee, commission or other compensation paid or payable to the County in connection with this contract, job, work, or service for the

County, excepting, however, the receipt of dividends on corporation stock.

AFFIDAVIT III

Neither I, nor the Contractor, nor any officer, director, or partners, or any of its employees who are directly involved in obtaining contracts with Howard County have been convicted of bribery, attempted bribery, or conspiracy to bribe under the laws of any state, or of the federal government for acts of omissions committed after July 1, 1977.

AFFIDAVIT IV

Neither I, nor the Contractor, nor any of our agents, partners, or employees who are directly involved in obtaining contracts with

Howard County have been convicted within the past 12 months of discrimination against any employee or applicant for employment, nor have we engaged in unlawful employment practices as set forth in Section 12.200 of the Howard County Code, or Subtitle 6 of

Title 20 of the State Government Article, Annotated Code of Maryland or, of Sections 703 and 704 of Title VII of the Civil Rights

Act of 1964 as amended.

AFFIDAVIT V

The Contractor:

i. Is not currently identified on the list created by the Maryland State Board of Public Works as a person engaging in investment activities in Iran as described in Section 17-702 of the Maryland State Finance and Procurement

Article ; or

ii. Is not currently engaging in investment activities in Iran as described in Section 17-702 of the Maryland State

Finance and Procurement Article.

If the person is unable to make the certification, it will provide the County, a detailed description of the Contractor’s investment activities in Iran.

AFFIDAVIT VI

If applicable, the Contractor has complied with Sections 14-101 through 14-108 of the Election Law Article of the Annotated Code of Maryland, which requires that every person that enters into, during any 24 month period, one or more contracts, leases, or other agreements with the State, a county, or an incorporated municipality, or their agencies, involving a cumulative consideration of at least $200,000 or more, shall file with the State Administrative Board of Election Laws a statement disclosing contributions to a candidate, or a series of such contributions, in a cumulative amount in excess of $500 made during the reporting period to a candidate for elective office in any primary or general election.

I do solemnly declare and affirm under the penalties of perjury that the contents of the foregoing affidavits are true and correct to the best of my knowledge, information and belief.

Signature

Printed Name

Title Rev. 01/29/2020