RFQual_Submittal_Forms_to_Complete.pdf

CERTIFICATION OF RESPONDENT

THIS FORM MUST BE PRINTED OUT, COMPLETED, AND UPLOADED BACK INTO OPENGOV

SOLICITATION: _______________________________________________________

(Number and Name Entered Above)

I/We (Insert Company Name) ________________________________agree to provide the goods and/ or services as stipulated in this solicitation and pricing as indicated in our solicitation response. I/We further agree that the below; undersigned is authorized by the (Insert Company Name) _______________________________ to bind the company in contract for the specified contract term. All exceptions (if applicable) are attached as an addendum to our solicitation response. I understand that the City may not accept exceptions to this solicitation. I/We further agree that if awarded the contract, to abide the terms and conditions of the contract and not to materially modify such terms without expressed written consent of the City:

Print Contact Name: _________________________

Contact Signature: ___________________________

Authorized Contact Title: _____________________

Contact Email Address: ______________________

Contact Telephone: _________________________

Contact Fax: ______________________________

Respondent's Address: _______________________________

City, State and ZIP Code: ______________________________

Milpitas Business License No.: __________________________

CSLB License No. (if applicable): ________________________

DIR Registration No. (if applicable): ______________________

NON-COLLUSION DECLARATION

SOLICITATION: _______________________________________________________

(Number and Name Entered Above)

The undersigned declares:

I am the ___________________ of ______________________________, the party making the foregoing solicitation response.

This solicitation response is not made in the interest of, or on behalf of, any undisclosed person, partnership, company, association, organization, or corporation. This response is genuine and not collusive or sham. The Respondent has not directly or indirectly induced or solicited any other Respondent to put in a false or sham solicitation response, and has not directly or indirectly colluded, conspired, connived, or agreed with any Respondent or anyone else to put in a sham solicitation response, or that anyone shall refrain from submitting a response. The Respondent has not in any manner, directly or indirectly, sought by agreement, communication, or conference with anyone to fix the submitted pricing of the Respondent or any other

Respondent, or to fix any overhead, profit, or cost element of the submitted pricing, or that of any other

Respondent, or to secure any advantage against the public body awarding the contract of anyone interested in the proposed contract. All statements contained in the solicitation response are true. The Respondent has not, directly or indirectly, submitted its pricing or any breakdown thereof, or the contents thereof, or divulged information or data relative thereto, or paid, and will not pay, any fee to any corporation, partnership, company association, organization, bid depository, or to any member or agent thereof to effectuate a collusive or sham solicitation response and has not paid, and will not pay, any person or entity for such purpose.

Any person executing this declaration on behalf of a Respondent 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 Respondent.

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct and that this declaration is executed on __________________ [date], at ___________________ [city], _______________ [state].

Business Name of Respondent: _______________________________________________________

Printed Name of Authorized Signer: _________________________________________________________

Title of Authorized Signer: _________________________________________________________________

Signature of Authorized Signer: ______________________________________________________________

RESPONDENT'S STATEMENT REGARDING INSURANCE COVERAGE

SOLICITATION: _______________________________________________________

(Number and Name Entered Above)

RESPONDENT HEREBY CERTIFIES that the Respondent has reviewed and understands the insurance coverage requirements specified in this solicitation. Should the Respondent be awarded a contract as a result of this solicitation, Respondent further certifies that the Respondent can meet the specified requirements for insurance, including insurance coverage of the subcontractors, and agrees to name the City as additional insured on all such insurance.

Name of Respondent (Person, Firm, or Corporation)

Signature of Respondent's Authorized Representative

Name and Title of Authorized Representative

Date of Signing

WORKER'S COMPENSATION INSURANCE CERTIFICATION

SOLICITATION: _______________________________________________________

(Number and Name Entered Above)

The Respondent shall execute the following form as required by the California Labor Code, Sections 1860 and 1861:

I am aware of the provisions of Section 3700 of the Labor Code, which require every employer to be insured against liability for worker's compensation or to undertake self-insurance in accordance with the provisions of that code, and I will comply with such provisions before commencing the performance of the work of this contract.

Name of Respondent (Person, Firm, or Corporation)

Signature of Respondent's Authorized Representative

Name and Title of Authorized Representative

Date of Signing

NONDISCRIMINATORY EMPLOYMENT CERTIFICATE

FORM MUST BE PRINTED OUT, COMPLETED, AND UPLOADED BACK INTO OPENGOV

SOLICITATION: _______________________________________________________

(Number and Name Entered Above)

Certificate Generally Consistent with a policy of nondiscrimination in employment on contracts of the City and in furtherance of the provisions of Section 1735 and 1777.6 of the California Labor Code a "contractor's obligation for nondiscriminatory employment certificate" as hereinafter set forth shall be attached and incorporated by reference as an indispensable and integral term of all solicitation specifications and contracts of the City for the construction, repair, or improvement of public works.

Contents of Certificate The Respondent's obligation for nondiscriminatory employment is as follows:

If awarded the contract and in providing the goods and/or services under the Agreement, the Respondent agrees as follows:

1. The Respondent will not discriminate against any employee or applicant for employment because of race, creed, color, national origin, ancestry, sexual orientation, political affiliation or beliefs, sex, age, physical handicap, medical condition, marital status or pregnancy (as those terms are defined by the California Fair Employment and Housing Act -- Government Code Section 12900-12996), except where such discrimination is based on a bona fide occupational qualification.

2. The Respondent will take positive action or ensure that applicants are employed and that employees are treated during employment, without regard to their race, creed, color, national origin, ancestry, sexual orientation, political affiliation or beliefs, sex, age, physical handicap, medical condition, marital status or pregnancy (as those terms are defined by the California Fair Employment and Housing Act -- Government Code Section 12900-12996), except where such discrimination is based on a bona fide occupational qualification. Such action shall include but not be limited to the following: Employment, upgrading, demotion, or transfer; recruitment or recruitment advertising; layoff or termination; rates of pay or other forms of compensation; and selection for training, including apprenticeship. The Respondent agrees to post in conspicuous places, available to employees and applicants for employment, notices to be provided by the City setting forth the provisions of this nondiscrimination clause.

3. The Respondent will, in all solicitations or advertisements for employees placed by or on behalf of the Respondent, state that all qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, sexual orientation, political affiliation or beliefs, sex, age, physical handicap, medical condition, marital status or pregnancy (as those terms are defined by the California Fair Employment and Housing Act -- Government Code Section 12900-12996), except where such discrimination is based on a bona fide occupational qualification.

4. The Respondent will send to each labor union or representative of workers, with which the Respondent has a collective bargaining agreement or other contract or understanding, a notice to be provided by the City advising the said labor union or workers' representative of the Respondent's commitments under this provision and shall post copies of the notice in conspicuous places available to employees and applicants for employment.

5. The Respondent will permit access to the Respondent's records of employment, employment advertisements, application forms, and other pertinent data and records by the City, the Fair Employment Practices Commission, or any other appropriate Agency of the State designated by the City for the purposes of investigation to ascertain compliance with the Respondent's obligation for nondiscriminatory employment provisions of the Agreement, or Fair Employment Practices statute.

6. A finding of willful violation of the nondiscriminatory employment practices article of this contract or of the Fair Employment Practices Act shall be regarded by the City as a basis for determining that as to future contracts for which the Respondent may submit quotes, the Respondent is a "disqualified Respondent" for being "non-responsible".

7. The City shall deem a finding of willful violation of the Fair Employment Practices Act to have occurred upon receipt of written notice from the Fair Employment Practices Commission that it has investigated and determined that the Respondent has violated the Fair Employment Practices Act and has issued an order under Labor Code Section 1426 or obtained an injunction under Labor Code Section 1429.

8. Upon receipt of any such written notice, the City shall notify the Respondent that unless he or she demonstrates to the satisfaction of the City within a stated period that the violation has been corrected, he or she shall be declared a "disqualified Respondent" until such time as the Respondent can demonstrate that he or she has implemented remedial measures, satisfactory to the City, to eliminate the discriminatory employment practices which constituted the violation found by the Fair Employment Practices Commission.

9. Upon receipt from any person of a complaint of alleged discrimination under any City contract, the City Administrator shall ascertain whether probable cause for such complaint exists. If probable cause for the complaint is found, the Administrator shall request the City Council to hold a public hearing to determine the existence of a discriminatory practice in violation of this contract.

10. In addition to any other remedy or action provided by law or the terms of this contract, the Respondent agrees that, should the Council determine after a public hearing duly noticed to the Respondent that the Respondent has not complied with the nondiscriminatory employment practices provisions of this contract or has willfully violated such provisions, the City may, without liability of any kind, terminate, cancel, or suspend this contract, in whole or in part. In addition, upon such determination, the Respondent shall, as a penalty to the City, forfeit a penalty of Twenty-Five Dollars and Zero Cents ($25.00) for each calendar day, or portion thereof, for each person who was denied employment as a result of such noncompliance. Such monies shall be recovered from the Respondent. The City may deduct any such penalties from any monies due to the Respondent from the City.

11. The Respondent certifies to the City that he or she has met or will meet the following standards for positive compliance, which shall be evaluated in each case by the City:

a. The Respondent shall notify all supervisors and other personnel officers in writing of the content of the nondiscrimination provision and their responsibilities under it.

b. The Respondent shall notify all sources of employee referrals (including unions, employment agencies, advertisements, Department of Employment) of the content of the nondiscrimination provision.

c. The Respondent shall file a basic compliance report as required by the City. Willfully false statements made in such reports shall be punishable as provided by law. The compliance report shall also specify the sources of the workforce and who has the responsibility for determining whom to hire, or whether or not to hire.

d. The Respondent shall notify the City of opposition to the nondiscrimination provision by individuals, firms or organizations during the period of this contract.

12. Nothing contained in this Respondent's Obligation for Nondiscriminatory Employment Certificate shall be construed in any manner to prevent the City from pursuing any other remedies that may be available at law.

13. The Respondent certifies to the City that the Respondent will comply with the following requirements with regard to all subcontractors and suppliers:

Signature of Respondent’s Authorized Representative

Name and Title of Authorized Representative

Date of Signing

a. The Respondent will include the provisions of the foregoing paragraphs (1) through (8) in all subcontracts and in any supply contract to be performed within the State of California, so that such provisions will be equally binding upon each subcontractor and each supplier.

b. The Respondent will take such action with respect to any subcontract or purchase order as the City may direct as a means of enforcing such provisions including sanctions for noncompliance: Provided, however, that in the event the Respondent becomes involved in, or is threatened with, litigations with a subcontractor or supplier as a result of such direction by the City, the Respondent may request the City to enter into such litigation to protect the interests of the City.

WAGE THEFT CERTIFICATION

SOLICITATION: _______________________________________________________

(Number and Name Entered Above)

Respondent certifies subject to penalty for perjury that the option checked below relating to the Respondent and its subcontractors’ status in regard to wage theft is true and correct:

Neither the Respondent nor any of its subcontractors have been found by a final court order or administrative action of an investigatory government agency to have violated federal, state or local wage and hour laws, including but not limited to the federal Fair Labor Standards Act, the California Labor Code and the Milpitas Minimum Wage Ordinance, within the past five (5) years from the bid submission deadline.

The Respondent or its subcontractors have been found by a final court order or administrative action of an investigatory government agency to have violated federal, state or local wage and hour laws, including but not limited to the federal Fair Labor Standards Act, the California Labor Code and the Milpitas Minimum Wage Ordinance, within the past five (5) years from the bid submission deadline. For each violation, the Respondent shall provide a copy of (i) the final court order and/or final administrative decision/action; and (ii) documents demonstrating either that the order/decision/action has been fully satisfied, or if the order/decision/action has not been fully satisfied, documents evidencing a payment or other alternative plan approved by the court/government agency to satisfy the order/decision/action and proof that the Respondent or its subcontractors are in compliance with that plan as of the bid submission deadline.

The City has exempted the Respondent from the requirements of the City of Milpitas Wage Theft Procurement Policy.

Signature:

Printed Name:

Title:

Firm Name:

Date:

REFERENCES

SOLICITATION: _______________________________________________________

(Number and Name Entered Above)

Respondent: _______________________________________________ (Legal Name of Entity Submitting Response)

List three references for work of a similar nature to that required by this solicitation within the last three years.

1. _________________________________ ____________________________ ___________ Name of Agency Agency Address Contact Name Contact Title Contact Telephone Contact Email Address Contract Period Contract Amount Description of Contract Scope

2. _________________________________ ________________________________________ Name of Agency Agency Address Contact Name Contact Title Contact Telephone Contact Email Address Contract Period Contract Amount Description of Contract Scope

3. _________________________________ ________________________________________ Name of Agency Agency Address Contact Name Contact Title Contact Telephone Contact Email Address Contract Period Contract Amount

Description of Contract Scope

I hereby certify that the Respondent performed the work listed above.

Signature of Respondent

Name Date

SOLICITATION AND/OR AGREEMENT EXCEPTIONS

SOLICITATION: _______________________________________________________

(Number and Name Entered Above)

Respondent hereby agrees that the goods and/or services to be provided will meet all the requirements set forth in this solicitation including, without limitation, all Attachments, and in particular the Exemplar Agreement document which is attached hereto and incorporated herein, unless deviations from them are clearly indicated in Respondent's submitted response to this solicitation. Any exceptions taken to the solicitation or Agreement must be submitted as an attachment to the Respondent's solicitation submittal, entitled “Exceptions to Solicitation and Contract,” and must be signed by Respondent’s authorized representative.

In the event Respondent takes exception to any provision in the solicitation or Agreement, those exceptions must be set forth with specificity. An explanation must be made for each item in which an exception is taken, giving in detail the extent of the exception, the reason for which it is taken, and the suggested change. Any such exception taken to the solicitation or Agreement may serve as a basis for rejection of the Respondent's solicitation submittal as nonresponsive. UNDER NO CIRCUMSTANCES

WILL THE CITY CONSIDER GENERAL STATEMENTS OF EXCEPTION OR RESERVATION

OF RIGHTS TO PROPOSE EXCEPTIONS AFTER THE SOLICITATION SUBMITTAL DEADLINE.

ANY SUCH STATEMENTS, RESERVATIONS OF RIGHTS, OR GENERIC RESPONSES MAY LEAD

TO THE SUBMITTED RESPONSE BEING DEEMED NONRESPONSIVE AND REJECTED WITHOUT

FURTHER CONSIDERATION.

Failure to comply with the requirements of this provision shall serve as a waiver of the Respondent’s right to challenge or otherwise take exception to any terms of the solicitation or the Agreement. Submittal of a brochure, general list of terms and conditions, or other manufacturer literature is desirable but may not be a substitution for this requirement.

Respondent does not take any exception to any part or provision in the solicitation or Agreement and waives its right to propose exceptions to the solicitation or Agreement following submission of its solicitation response.

Respondent does take exception to specific provisions in the solicitation or Agreement and has attached hereto a list of each exception taken with reference to the specific section or provision it takes exception to, the proposed revised language ,and the basis for the exception. Respondent acknowledges and agrees that it has not submitted any general or generic statements of exception or reservation of rights to propose exceptions after response submission, which will be rejected by the City and may lead to rejection of the solicitation response in its entirety as nonresponsive.

Respondent further acknowledges and agrees its failure to include exceptions in the form required by this solicitation shall constitute a waiver of its right to propose exceptions to the solicitation or Agreement following submission of its solicitation response.

Signature:

Printed Name:

Title:

Firm Name:

Date: