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 services as stipulated in this solicitation at pricing indicated in our response. I/We further agree that the below undersigned is authorized by the (Insert Company Name) to contractually bind the company 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 requested exceptions to the this solicitation or any resulting contract. I/We further agree that, if awarded the contract, we will abide by the terms and conditions of the contract and not materially modify such terms without express written consent of the City.

Print Contact Name: ___________

Contact Signature: ___________

Authorized Contact Title: ___________

Contact Email Address: ___________

Contact Telephone: ___________

Respondent’s (Company) Address: ___________

City, State and ZIP Code: ___________

California Secretary of State No.: ___________

Milpitas Business License No.: ___________

CSLB License No. (if applicable): ___________

DIR Registration No. (if applicable): ___________ https://bizfileonline.sos.ca.gov/search/business https://www.milpitas.gov/241/Business-License-Center

NON-COLLUSION DECLARATION

The undersigned declares:

I am the of , the party submitting the 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 a sham. The Respondent has not directly or indirectly induced or solicited any other responder to put in a false or sham response, and has not directly or indirectly colluded, conspired, connived, or agreed with any responder 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 Respondent’s pricing or any other responder, or to fix any overhead, profit, or cost element of the submitted price, or that of any other responder, or to secure any advantage against the public body awarding the contract of anyone interested in any 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 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].

Name of Respondent:

Signature:

Name:

Title:

RESPONDENT'S STATEMENT REGARDING INSURANCE COVERAGE

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

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

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

NONDISCRIMINATORY EMPLOYMENT CERTIFICATE

Certificate Generally Consistent with a policy of nondiscrimination in employment on contracts of the City and in furtherance of the provisions of Sections 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 services under the contract, Respondent agrees as follows:

1. 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. 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. Respondent agrees to post in conspicuous places, accessible by employees and applicants for employment, notices setting forth provisions of this nondiscrimination clause.

3. 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. Respondent will send to each labor union or representative of workers, with which Respondent has a collective bargaining agreement or other contract or understanding, a notice 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. 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 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 Respondent is a "disqualified Respondent" for being "non-responsible" for any future solicitations or contracts for which the Respondent may submit responses.

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 Respondent that unless it demonstrates to the satisfaction of the City within a stated period that the violation has been corrected, Respondent shall be declared a "disqualified Respondent" until such time as Respondent can demonstrate that it 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 shall ascertain whether probable cause for such complaint exists. If probable cause for the complaint is found, City staff shall request the City Council to hold a public hearing to determine the existence of a discriminatory practice in violation of the contract resulting from this solicitation.

10. In addition to any other remedy or action provided by law or the terms of this contract, Respondent agrees that, should the City 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, Respondent shall forfeit a penalty of Twenty-Five Dollars and Zero Cents ($25.00) to City 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. Respondent certifies to the City that it has met or will meet the following standards for positive compliance, which shall be evaluated in each case by the City:

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

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

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

a. Respondent will include applicable provisions of this Nondiscriminatory Employment Certificate 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. 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, Respondent may request the City to enter into such litigation to protect the interests of the City.

Respondent

Signature of Respondent’s Authorized Representative

WAGE THEFT CERTIFICATION

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 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 solicitation submission deadline.

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 solicitation submission deadline. For each violation, 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 has been 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 solicitation submission deadline.

Printed Name:

Firm Name:

Date:

REFERENCES

Respondent:

(Legal Name of Entity Submitting Respondent)

List three references for work of a similar nature to that specified for this solicitation performed 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 Services Performed

2.

3.

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

Signature of Respondent Name Date

SOLICITATION AND/OR AGREEMENT EXCEPTIONS

Respondent hereby agrees that the goods and services provided will meet all the requirements of this solicitation including, without limitation, all attachments and exhibits and, in particular, the document attached as Attachment B (“Agreement”) which is incorporated herein by this reference, unless deviations from them are clearly indicated in the Respondent solicitation submittal. Any exceptions taken to this solicitation or Agreement must be submitted as an attachment to Respondent’s solicitation response, 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 this solicitation or Agreement, those exceptions must be set forth with specificity. An explanation must be made for each item to 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 this 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 RESPONSE SUBMISSION. ANY SUCH STATEMENTS, RESERVATIONS OF RIGHTS, OR

GENERIC RESPONSES MAY LEAD TO RESPONDENT’S SUBMISSION BEING DEEMED

NONRESPONSIVE AND REJECTED WITHOUT FURTHER CONSIDERATION. FURTHERMORE, THE

CITY WILL NOT ACCEPT ADDITIONAL EXCEPTIONS AFTER THE FACT. ALL REQUESTED

EXCEPTIONS MUST BE SUBMITTED WITH YOUR SOLICITATION RESPONSE.

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 this solicitation or the Agreement.

� 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 solicitation submission, which will be rejected by the City and may lead to rejection of the Respondent’s solicitation submittal 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.

Printed Name:

Firm Name:

Date: