RFP6180SD Forms Package.pdf

STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION

DRUG-FREE WORKPLACE PROGRAM CERTIFICATION

375-040-18

PROCUREMENT

03/17

DOT-RFP-23-6180SD

287.087 Preference to businesses with drug-free workplace programs. --Whenever two or more bids, proposals, or replies that are equal with respect to price, quality, and service are received by the state or by any political subdivision for the procurement of commodities or contractual services, a bid, proposal, or reply received from a business that certifies that it has implemented a drug-free workplace program shall be given preference in the award process. In order to have a drug-free workplace program, a business shall:

(1) Publish a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the workplace and specifying the actions that will be taken against employees for violations of such prohibition.

(2) Inform employees about the dangers of drug abuse in the workplace, the business's policy of maintaining a drug-free workplace, any available drug counseling, rehabilitation, and employee assistance programs, and the penalties that may be imposed upon employees for drug abuse violations.

(3) Give each employee engaged in providing the commodities or contractual services that are under bid a copy of the statement specified in subsection (1).

(4) In the statement specified in subsection (1), notify the employees that, as a condition of working on the commodities or contractual services that are under bid, the employee will abide by the terms of the statement and will notify the employer of any conviction of, or plea of guilty or nolo contendere to, any violation of Chapter 893 or of any controlled substance law of the United States or any state, for a violation occurring in the workplace no later than 5 days after such conviction.

(5) Impose a sanction on, or require the satisfactory participation in a drug abuse assistance or rehabilitation program if such is available in the employee's community by, any employee who is so convicted.

(6) Make a good faith effort to continue to maintain a drug-free workplace through implementation of this section.

Does the individual responding to this solicitation certify that their firm has implemented a drug-free workplace program in accordance with the provision of Section 287.087, Florida Statutes, as stated above?

Y E S

NAME OF BUSINESS:

NO

ANTICIPATED DBE PARTICIPATION STATEMENT

375-040-63

PROCUREMENT

02/07

The Prime contractor is encouraged to complete this form and submit this form with your bid/price proposal/reply.

Submission of this form is not mandatory.

Procurement Number: DOT-RFP-23-6180SD

Contractor's Name:

Contractor's FEID Number:

Is the prime contractor a Florida Department of Transportation Certified Disadvantaged Business Enterprise (DBE)?

( yes ) ( no )

Expected amount of contract dollars to be subcontracted to DBE(s): $

OR

It is our intent to subcontract % of the contract dollars to DBE(s). Listed below are the proposed DBE sub-contractors:

DBE (s) Name Type of Work/Specialty Dollar Amount/Percentage

Submitted by: Title:

(Type or Print)

Date:

Note: This information is used to track and report anticipated DBE participation in FDOT contracts. The anticipated DBE amount will not become part of the contractual terms.

BID OPPORTUNITY LIST FOR COMMODITIES & CONTRACTUAL

SERVICES

375-040-62

01/16

Prime Contractor:

Address/Phone Number:

Procurement Number: DOT-RFP-23-6180SD

49 CFR Part 26.11 The list is intended to be a listing of all firms that are participating, or attempting to participate, on DOT-assisted contracts. The list must include all firms that bid on prime contracts, or bid or quote subcontracts and supplies materials on DOT-assisted projects, including both DBEs and non-DBEs. This list must include all subcontractors contacting you and expressing an interest in teaming with you on a specific DOT-assisted project. Prime contractors must provide information for Numbers 1, 2, 3 and 4, and should provide any information they have available on Numbers 5, 6, and 7 for themselves, and their subcontractors.

1. Federal Tax ID Number: 6. DBE 7. Annual Gross Receipts

2. Firm Name: Non-DBE Less than $1 million

3. Phone: Between $1 - $5 million

4. Address: Between $5 - $10 million Between $10 - $15 million More than $15 million

5. Year Firm Established:

3. Phone: Between $1 - $5 million

4. Address: Between $5 - $10 million Between $10 - $15 million

3. Phone: Between $1 - $5 million

4. Address: Between $5 - $10 million Between $10 - $15 million

3. Phone: Between $1 - $5 million

4. Address: Between $5 - $10 million Between $10 - $15 million

AS APPLICABLE, PLEASE SUBMIT THIS FORM WITH YOUR: BID SHEET (Invitation to Bid – ITB) PRICE PROPOSAL (Request for Proposal – RFP) REPLY (Invitation to Negotiate – ITN)

E-VERIFY

375-031-06

PROCUREMENT

OGC – 10/21

Contract No: DOT-RFP-23-6180SD

Financial Project No(s):

Project Description: Districtwide Communications Programs and Special Projects for the Florida Department of Transportation

In accordance with the contract, the Vendor/Consultant/Contractor hereby acknowledges and certifies compliance with Section 448.095, Florida Statutes. The Vendor/Consultant/Contractor shall register with and use the E-Verify system to verify the work authorization status of all newly hired employees. The Vendor/Consultant/Contractor shall utilize the U.S. Department of Homeland Security’s E-Verify system, in accordance with the terms governing use of the system. The Vendor/Consultant/Contractor shall comply with Section 448.095, Florida Statutes, for the duration of the contract term, including any extensions or renewal periods.

Company/Firm:

Authorized Signature:

Title:

407347-4-32-01

Florida Statutes:

287.135

STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION

VENDOR CERTIFICATION REGARDING

SCRUTINIZED COMPANIES LISTS

375-030-60

OGC – 06/18

Respondent Vendor Name:

Vendor FEIN:

Vendor’s Authorized Representative Name and Title:

Address:

City: State: Zip:

Phone Number:

Email Address:

Section 287.135, Florida Statutes prohibits a company from bidding on, submitting a proposal for, or entering into or renewing a contract for goods or services of any amount if, at the time of contracting or renewal, the company is on the Scrutinized Companies that Boycott Israel List, created pursuant to Section 215.4725, Florida Statutes, or is engaged in a boycott of Israel. Section 287.135, Florida Statutes, also prohibits a company from bidding on, submitting a proposal for, or entering into or renewing a contract for goods or services of $1,000,000 or more, that are on either the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector Lists which were created pursuant to s. 215.473, Florida Statutes.

As the person authorized to sign on behalf of Respondent, I hereby certify that the company identified above in the section entitled “Respondent Vendor Name” is not listed on either the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List, or the Scrutinized Companies that Boycott Israel List. I further certify that the company is not engaged in a boycott of Israel. I understand that pursuant to section 287.135, Florida Statutes, the submission of a false certification may subject company to civil penalties, attorney’s fees, and/or costs.

Certified By:

who is authorized to sign on behalf of the above referenced company.

Authorized Signature Print Name and Title:

DOT-RFP-23-6180SD