salem Bid_26-23_Line_Striping_Program_103403.pdf

COUNTY OF SALEM

SALEM, NEW JERSEY

BID # 26-23

SPECIFICATIONS FOR

PROVIDING ROADWAY LINE STRIPING SERVICES FOR THE

BID OPENING: SEPTEMBER 11, 2026

11:00 AM PREVAILING TIME

SALEM COUNTY ADMINISTRATION BUILDING

110 FIFTH STREET, SUITE 400

SALEM, NEW JERSEY 08079

(856) 935-7510 Phone

(856) 339-4190 Facsimile

Please note some of the forms have been updated.

Please review all forms, follow instructions, and complete as required.

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BID NOTICE

COUNTY OF SALEM, NEW JERSEY

NOTICE IS HEREBY GIVEN that sealed Bids will be received by the Purchasing Agent for the County of Salem, State of New Jersey on September 11, 2026 at 11:00 am prevailing time at the Salem County Administration Building, 110 Fifth Street, Suite 400, Salem, New Jersey, 08079 at which time and place bids will be opened and read in public for:

SPECIFICATIONS FOR PROVIDING ROADWAY LINE STRIPING SERVICES FOR THE COUNTY

OF SALEM; RFP #26-23

Bid Documents may be downloaded at http://salempurchasing.org

Purchasing Portal Commodity Code(s):

1. Construction – Road

2. Public Works, Park Equipment, and Construction Services

Bidders are required to comply with the requirements of P.L. 1975, C. 127 (N.J.A.C. 17:27) Affirmative Action, P.L. 1977.

C. 33, as amended by P.L. 2016, C. 43 (N.J.S.A 52:25-24.2) Corporate Disclosure, P.L 2009, C. 315 New Jersey Business Registration and P.L. 1999, C. 238, Public Works Contractor Registration and the 1963 Revised Statutes of New Jersey, Chapter 150, Prevailing Wages. The successful contractor shall be required to submit Certified Payroll Forms on this project.

Each bidder shall be required to submit a Bid Security in the amount of 10% of their bid (but not over $20,000.00) with their bid. Each bidder shall also be required to submit a Consent of Surety with their bid.

Any questions regarding the specifications prior to the bid opening may be addressed to the Office of the County Purchasing Agent, 110 Fifth Street, Suite 400, Salem, New Jersey, 08079 pursuant to the timeline(s) stated within the bid specification;

E-mail: purchasing@salemcountynj.gov. Telephone (856) 935-7510.

Proposals are being solicited through a fair and open process in accordance with N.J.S.A. 19:44A-20.2, et seq., and as such, contractors are exempt from the limitations on making political contributions under that law. Further, for that reason, as well as because of a language in the New Jersey’s Annual Appropriations Act, refusal to disclose campaign contributions otherwise required by N.J.S.A. 19:44A-20.2 et seq. and 19:44A-20.25 et seq., will not adversely affect your consideration for award.

By order of the Board of County Commissioners of the County of Salem.

Jeffrey T. Ridgway, Jr.

Purchasing Agent

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TABLE OF CONTENTS

BID INVITATION 2

TABLE OF CONTENTS 3

BID CHECKLIST 4-6

STATEMENT OF AUTHORITY (EXHIBIT A) 7

BID EXCEPTIONS FORM (EXHIBIT B) 8-10

BID GUARANTEE (EXHIBIT C) 11

CONSENT OF SURETY (EXHIBIT D) 12

LETTER OF CREDIT (EXHIBIT E) 13-14

PERFORMANCE BOND (EXHIBIT F) 15-17

LABOR AND MATERIAL PAYMENT BOND (EXHIBIT G) 18-20

STATEMENT OF OWNERSHIP (EXHIBIT H) 21-22

EEO/AFFIRMATIVE ACTION COMPLIANCE NOTICE (EXHIBIT I) 23-25

AMERICANS WITH DISABILITIES ACT LANGUAGE (EXHIBIT J) 27

CERTIFICATION REGARDING DEBARMENT (EXHIBIT K.1) 28-29

FEDERAL NON-DEBARMENT CERTIFICATION (EXHIBIT K.2) 30-34

NON-COLLUSION AFFIDAVIT (EXHIBIT L) 35

ACKNOWLEDGEMENT OF RECEIPT OF ADDENDA (EXHIBIT M) 36

REQUEST FOR REFERENCE FORM (EXHIBIT N) 37

VENDOR INFORMATION SHEET (EXHIBIT O) 38

BIDDERS DATA SHEET AND QUESTIONNAIRE (EXHIBIT P) 39

IDENTIFICATION OF SUBCONTRACTORS (EXHIBIT Q) 40

EQUIPMENT CERTIFICATION (EXHIBIT R) 41

INSURANCE REQUIREMENTS (EXHIBIT S) 42-44

DISCLOSURE OF INVESTMENTS ACTIVITIES IN IRAN (EXHIBIT T) 45-46

RUSSIA BELARUS BUSINESS PROHIBITION FORM (EXHIBIT U) 47

FORM W-9 (EXHIBIT V) 48

PUBLIC WORKS FOR 10% RULE (EXHIBIT W) 49

CONFLICT OF INTEREST POLICY (EXHIBIT X) 50-52

GENERAL INSTRUCTIONS AND CONDITIONS 53-73

OFFICIAL BID SHEET (EXHIBIT Y) 74-75

TECHNICAL SPECIFICATIONS AND SPECIAL PROVISIONS 76-107

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BID CHECKLIST

Failure by the bidder to submit with their Bid all of the items that are checked below may cause the Bid to be considered non-responsive.

Required with Item Read, Initialed Receipt of Bid and Submitted

X Statement of Authority (Exhibit A) ____________

X Bid Exceptions Form (Exhibit B) ____________

X Bid Guarantee (Exhibit C) ____________

X Consent of Surety/Letter of Credit (Exhibit D/E) ____________

X Statement of Corporate Ownership ____________ Pursuant to N.J.S.A. 52:25-24.2 (Exhibit H)

X EEO/Affirmative Action Compliance ____________ Notice Pursuant to N.J.S.A. 10:5-31 et seq. and N.J.A.C. 17:27 (Exhibit I)

X Certification Regarding Debarment ____________ (Exhibits K.1 and K.2)

X Non- Collusion Affidavit (Exhibit L) ____________

X Acknowledgement of Receipt of ____________ Addenda Form Pursuant to

N.J.S.A. 40A:11-23.2.e. (Exhibit M)

X Request for References Form (Exhibit N) ____________

X Vendor Information Sheet (Exhibit O) ____________

X Bidders Data Sheet and Questionnaire ____________ (Exhibit P)

X Identification of Subcontractors (Exhibit Q) ____________

X Equipment Certification (Exhibit R) ____________

X Official Bid Sheet (Exhibit Y) ____________

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The items that are checked below shall be submitted no later than the time period indicated.

Required as Item Read, Initialed Conditioned Shall Submit

X Performance Bond (Exhibit F) ____________ (Due with the executed contract)

X Labor and Material Payment Bond (Exhibit G) ____________ (Due with the executed contract)

X Public Works Contractor Registration ____________

Certificate(s) for the General or Prime Contractor and any Subcontractor submitted in the bid proposal with a date effective at the time the proposal is submitted. (Due prior to award)

X New Jersey Business Registration ____________ Certificate (Due prior to award)

X Certificate(s) of Insurance as specified ____________ in the Bid Document (Exhibit S) (Due with executed contract)

X Disclosure of Investment Activities In Iran (Exhibit T) (Due prior to award)

X Russia Belarus Business Prohibition ___________ (Exhibit U) (Due prior to award)

X W-9 Form (Exhibit V) ___________ (Due prior to award)

X Public Works 10% Rule (Exhibit W) ____________

The items that are checked below are to be reviewed by the bidders.

Review Required Item Read and Initialed

X Americans with Disabilities _____________ Act Language – (Exhibit J)

X Conflict of Interest Policy _____________ (Exhibit X)

X General Instruction/Conditions _____________

X Technical Specifications _____________

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THE ITEMS AND/OR FORMS INDICATED ABOVE SHALL BE REVIEWED AND/OR SUBMITTED

WITH YOUR BID. THIS CHECKLIST IS PROVIDED FOR INFORMATIONAL PURPOSES ONLY. ALL

REQUIRED DOCUMENTATION MAY NOT BE LISTED ABOVE AND IT SHALL BE THE

RESPONSIBILITY OF THE BIDDER TO CAREFULLY REVIEW THE COMPLETE BID PACKAGE,

FAMILIARIZE THEMSELVES WITH THE REQUIREMENTS OF THIS BID, AND TO SUBMIT WITH

THEIR BID ALL REQUIRED DOCUMENTATION.

SIGNATURE

The undersigned hereby acknowledges that they have submitted and/or reviewed the above listed requirements:

Name of Company: _____________________________________________________________

Signature: _____________________________________________________________________

Print Name: ___________________________________________________________________

Title: _________________________________________________________________________

Date: _________________________________________________________________________

END OF BID CHECKLIST

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EXHIBIT A

STATEMENT OF AUTHORITY

BID SUBMITTED FOR:

COMPANY: ____________________________________________________________

ADDRESS: _____________________________________________________________

BID SUBMITTED BY: ____________________________________________________

(Print Name of Company Officer)

SIGNATURE: ___________________________________________________________

(Signature of Company Officer) ***

TITLE: _____________________________________ DATE: _____________________

TELEPHONE: _______________________________ EXTENSION: _______________

FACSIMILE: ____________________________________________________________

EMAIL ADDRESS: _______________________________________________________

TAXPAYER IDENTIFICATION NUMBER: __________________________________

*** This Exhibit must be signed by a Company Officer, who has the legal authority to bind the Company to a contract, in order to be accepted by the County as a valid bid.

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EXHIBIT B

BID EXCEPTIONS FORM

Exceptions, if any, to the bid specifications, shall be noted and described below.

Please note that bids received without any exceptions noted and described below shall be assumed to be in complete compliance with the bid specifications.

Please note that failure by the bidder to note and describe below exceptions to the bid specifications shall in no way provide relief to contractors supplying products or materials which do not meet the bid specifications.

Contractors supplying products or materials which are not noted and identified below shall be subject to legal action.

Do you have any exceptions to the specifications? Yes No . If yes, note and describe below your exceptions.

EXCEPTION # 1: Describe here with specificity the exact nature of your Exception # 1:

Describe here with specificity how with Exception # 1 your bid still meets the requirements of this specification:

EXCEPTION # 2: Describe here with specificity the exact nature of your Exception # 2:

Describe here with specificity how with Exception # 2 your bid still meets the requirements of this specification:

EXCEPTION # 3: Describe here with specificity the exact nature of your Exception # 3:

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Describe here with specificity how with Exception # 3 your bid still meets the requirements of this specification:

EXCEPTION # 4: Describe here with specificity the exact nature of your Exception # 4:

Describe here with specificity how with Exception # 4 your bid still meets the requirements of this specification:

EXCEPTION # 5: Describe here with specificity the exact nature of your Exception # 5:

Describe here with specificity how with Exception # 5 your bid still meets the requirements of this specification:

EXCEPTION # 6: Describe here with specificity the exact nature of your Exception # 6:

Describe here with specificity how with Exception # 6 your bid still meets the requirements of this specification:

EXCEPTION # 7: Describe here with specificity the exact nature of your Exception # 7:

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Describe here with specificity how with Exception # 7 your bid still meets the requirements of this specification:

IF YOU HAVE MORE EXCEPTIONS, MAKE COPIES OF THIS

EXCEPTION FORM, COMPLETE THE FORMS AND ATTACH THEM TO THE FRONT OF YOUR

BID SUBMISSION

Form Completed by: ______________________________________________________ (Print Name)

(Signature)

Title: _____________________________________ Date: _________________________

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EXHIBIT C

SAMPLE FORM OF BID BOND

A. We, the undersigned as Principal and

________________________________________ as Surety, are hereby held and firmly bound unto _____________________________ in the penal sum of _____________________________Dollars

($_______________), lawful money of the United States for the payment of which well and truly to be made, we hereby jointly and severally bind ourselves, our heirs, executors, administrators, successors and assigns. Signed this ___________ day of ____________, 20 ______.

B. THE CONDITION of the above obligation is such that whereas the Principal has submitted to the_________________________________________________, a certain bid attached hereto and hereby made a part of hereto and hereby made a part of hereof, to enter into a contract in writing for the (insert type of work)

C. NOW THEREFORE:

If said bid shall be rejected, or in the alternate, if said bid shall be accepted and the Principal shall execute and deliver a contract in the form of Agreement required by the Bid Documents and for the payment of all persons performing labor or furnishing materials in connection therewith, and shall in all respects perform the agreement created by the acceptance of said bid. Then this obligation shall be void, otherwise the same shall remain in force and effect, it being expressly understood and agreed that the liability of the surety for any and all claims hereunder shall, in no event, exceed the penal amount of this obligation as herein stated.

D. THE SURETY for value received, hereby stipulates and agrees that the obligations of said Surety and its bond shall in no way be impaired or affected by an extension of the time within the "OBLIGEE" may accept such bid. And said Surety does hereby waive notice of any such extension.

E. IN WITNESS WHEREOF, the Principal and the Surety have hereunto set their hands and seals, and such of them as corporations have caused their corporate seals to be hereto fixed and these presents to be signed by their proper officers, the day and year set forth above.

____________________________________(L.S.)

PRINCIPAL

SURETY

(SEAL) ____________________________________

BY

NOTE: Bid Bond must be signed by an authorized agent or representative of a surety company and not by the individual or company submitting the bid.

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EXHIBIT D

SAMPLE FORM OF CONSENT OF SURETY

BOND NO._____________________________

(INSERT YOUR BOND NO. HERE)

The ___________________________________, a Corporation organized and

(NAME OF YOUR INSURANCE COMPANY)

existing under the laws of the State of ______________________________ and licensed to do business in the State of New Jersey, hereby consents and agrees that if the contract for the _______________________________________

(INSERT BID NO.

________________________________________________________________________AND

ITEMS WHICH YOU ARE BIDDING).

be awarded to ______________________________.

(NAME OF YOUR COMPANY)

the undersigned Corporation agrees with the said County of Salem, 164 West Broad Street, Bridgeton, New Jersey 08302 to execute the final bond as required by the specifications and to become the surety in the full amount of the price bid for the faithful performance of the contract.

In Witness Whereof, the undersigned Corporation has caused this agreement to be signed by its duly authorized representative and its Corporate Seal to be hereto affixed this________________ day of _____________________, 20 ____.

The_______________________________

(NAME OF INSURANCE COMPANY)

By _______________________________

(ATTORNEY-IN-FACT)

Countersigned by:

NOTE: Consent of Surety must be signed by an authorized agent or representative of a surety company and not by the individual or company submitting the bid.

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EXHIBIT E

SAMPLE FORM OF TERMS OF LETTER OF CREDIT

1. AMOUNT: The amount of this letter of credit shall be for the sum of

(Amount of Contract)

2. TERM: The term of this letter of credit shall be in effect and irrevocable for a period commencing on the date of execution of the agreement between the County of Salem and________________________________________________.

(Name of Contractor) and terminating one (1) year after the date of completion and final acceptance by the

County of the work performed pursuant to County Bid No.:

(Bid No. and description of services/material to be provided)

3. CAUSES FOR PROCEEDING AGAINST LETTER OF CREDIT: The COUNTY shall have the absolute right to proceed against this letter of credit if:

(a) Contractor shall fail to faithfully perform according to the terms of the contract and

COUNTY Bid, or any changes or modifications therein made as therein provided; or Contractor shall fail to indemnify and save harmless the County, its officers, agents and servants, and each and every one of them against and from all suits and costs of every kind and description and from all damages which the County, or any of its officers, agents or servants may be put by reason of injury to the person or property of others resulting from the performance of said work or through the negligence of Contractor, or through any improper or defective machinery, implements or appliances used by contractor in the aforesaid work or through any act or omission on the part of

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Contractor, its agents, servants or employees; or contractor shall fail to further indemnify and save harmless the County, its officers, agents and servants from all suits and actions of any kind or character whatsoever, which may be brought or instituted by any subcontractors, materialman or laborer who has performed work or furnished materials in or about the work required to be done pursuant to said contract, or by or on account of, any claims or amount recovered for any infringement of patent, trademark, or copyright; or _____________________________________

(Name of Bank) agreeing and assenting that this undertaking shall be for the benefit of any subcontractor, materialman, laborer, person, firm or corporation having a just claim, as well as for the County, whether or not the said material and labor enter into and become component parts of the work or improvement or in any amendment, extension or addition to said contract; or

(b) Contractor shall fail to pay all lawful sums of subcontractors, materialman, laborers, persons, firms or corporations for labor performed or materials, provisions, provender or other supplies or teams, fuels, oils, implements or machinery furnished, used or consumed in the carrying forward, performing or completing of said contract; or

(c) Contractor shall fail to well and truly keep and perform all the obligations, agreements, terms and conditions of such contract, on its part to be kept and performed and Contractor shall be responsible for poor workmanship done or poor materials furnished under said contract for a period of one (1) year from the date of the completion and final acceptance by the County, and Contractor shall pay for all labor performed and furnished and for all materials used in correcting any poor workmanship done and replacing any poor materials furnished.

It is further agreed that any alterations which may be made in the terms of the contract or in the work to be done or materials to be furnished or labor to be supplied or performed under it or the giving by the County of any extension of time for the performance of the contract shall not in any way release Contractor, its heirs, executors, administrators, successors or assigns, from its liability hereunder.

NOTE: Letter of Credit must be signed by an authorized agent or representative of a bank or similar financial institution and not by the individual or company submitting the bid.

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EXHIBIT F

SAMPLE FORM OF PERFORMANCE BOND

We, the Undersigned as Principal, and___________________________________________________________ a Corporation organized and existing under the laws of the State of________________________ and authorized to do business in the State of New Jersey as surety are held and firmly bound unto ____________________________hereinafter called the Owner as hereinafter set forth, in the full and just several sums of

(a)__________________________________________________________________________

___________________________________________________Dollars($________________) for faithful performance of the contract as hereinafter designated in Paragraph "A" and

(b)__________________________________________________________________________

____________________________________________________Dollars($_______________) for payment of labor and material as hereinafter designated in Paragraph "B" and

(c)__________________________________________________________________________

____________________________________________________Dollars($_______________) for maintenance as hereinafter designated in Paragraph "C"; lawful money of the United States of America; to be paid to the Owner, or its Assigns, to which payment well and truly to be made and done, we bind ourselves, our heirs, executors, administrators and successors, jointly and severally, firmly by these presents.

Sealed with our respective seals and dated this __________day of _____________________________, 20 _____

WHEREAS, the above bonded Principal has entered into a contract with the

Owner dated the ________________day of _________________________, 20 ______ for___________________________________________________________________________ upon certain terms and conditions in said contract more particularly mentioned; and

WHEREAS, it is one of the conditions of the award of the Owner pursuant to which said contract is about to be entered into, that these presents be executed.

NOW, THEREFORE, THE CONDITIONS OF THIS OBLIGATION ARE SUCH:

A. That if the Principal shall faithfully perform the contract on its part to be performed according to the terms of said contract, or any changes or modifications therein made as therein provided; and shall indemnify and save harmless the party of the first part mentioned in the contract aforesaid, its officers, agents and servants, and each and every one of them against and from all suits and costs of every kind and description and from all damages which the said party of the first part in said contract mentioned, or any of its officers, agents or servants may be put by reason of injury

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(Sample Form of Performance Bond – continued) to the person or property of others resulting from the performance of said work or through the negligence of the said party of the second part to said contract, or through any improper or defective machinery, implements or appliances used by the said party of the second part in the aforesaid work or through any act or omission on the part of the said party of the second part of its agents, servants or employees, and shall further indemnify and save harmless the party of the first part mentioned in the contract aforesaid its officers, agents and servants from all suits and actions of any kind or character whatsoever, which may be brought or instituted by any subcontractor, materialman or laborer who has performed work or furnished materials in or about the work required to be done pursuant to the said contract or by or on account of, any claims or amount recovered for any infringement of patent, trademark, or copyright; then this part of this obligation designated as part "A" shall be void; otherwise the same shall remain in full force and effect, it being expressly understood and agreed that the liability of the surety for any and all claims hereunder shall in no event exceed the penal amount of this obligation as herein stated.

B. That if the said Principal shall pay all lawful claims of subcontractors, materialmen, laborers, persons, firms or corporations for labor performed or materials, provisions, provender or other supplies or items, fuels, oils, implements or machinery furnished, used or consumed in the carrying forward, performing or completing of said contract; we agreeing and assenting that this undertaking shall be for the benefit of any subcontractor, materialman, laborer, person, firm or corporation having a just claim, as well as for the obligee herein; whether or not the said material and labor enter into and become component parts of the work or improvement or in any amendment, extension or addition to said contract, then this part of this obligation designated part "B", shall be void, otherwise the same shall remain in full force and effect.

C. That if the said Principal shall well and truly keep and perform all the obligations, agreements, terms, and conditions of such contract, on the Principal's part to be kept and performed and said Principal shall be responsible for poor workmanship done or poor materials furnished under said contract for a period of one year from the date of the completion and final acceptance by the party of the first part and mentioned in the contract, and said Principal shall pay for all labor performed and furnished and for all materials used in correcting any poor workmanship done and replacing any poor materials furnished, then this part of this obligation designated part "C", shall be void; otherwise the same shall remain in full force and effect.

It is further agreed that any alterations which may be made in the terms of the contract or in the work to be done or materials to be furnished or labor to be supplied or performed under it or the giving by the Owner of any extension of time for the performance of the Contract or the reduction of the retained percentages as permitted by the Contract or any other forbearance on the part of either the Owner or the Principal to the other, shall not in any way release the Principal and the

Surety or Sureties or either or any of them, their heirs, executors, administrators, successors or assigns, from their liability hereunder, notice to the Surety or Sureties of any alterations, extension or forbearance being hereby waived.

It is further agreed that in case of default in, and/or any action arising out of rights and liabilities secured by this obligation or any part hereto or any person claiming by or through it, either may use for the purpose of establishing its, or their claim, a copy of this obligation certified by the Owner, and the action, or actions, if any, arising on the within bond, shall not be a bar to any subsequent action that may arise through any liability incurred in any other action herein, and based upon any other part of this obligation.

IN WITNESS WHEREOF, the said Principal and Surety have duly executed this bond under their seals the day and year above written.

If Principal is an individual:

(Sample Form of Performance Bond – continued on next page)

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(Sample Form of Performance Bond – continued)

Witness:

___________________________ By____________________(SEAL)

Surety

___________________________ By______________________ Attorney-in-fact (Corporate Seal)

If Principal is a partnership: _________________________ Witness: Principal

__________________________ _______________________(SEAL)

Partner

__________________________ ________________________(SEAL)

Partner

Surety

By________________________ Attorney-in-fact (Corporate Seal)

If Principal is a corporation: __________________________ Attest: Principal

___________________________ By_________________________ Secretary President

Corporate Seal:

Attest:

__________________________ By________________________ Attorney-in-fact (Corporate Seal)

Approved as to Form_______________, 20_____

Counsel

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EXHIBIT G

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EXHIBIT H

STATEMENT OF OWNERSHIP DISCLOSURE

N.J.S.A. 52:25-24.2 (P.L. 1977, c.33, as amended by P.L. 2016, c.43)

This statement shall be completed, certified to, and included with all bid and proposal submissions. Failure to submit the required information is cause for automatic rejection of the bid or proposal. Please read and review the General Instructions and Conditions section related to this Statement.

Name of Organization:_________________________________________________________________

Organization Address:_________________________________________________________________

Part I Check the box that represents the type of business organization:

Sole Proprietorship (skip Parts II and III, execute certification in Part IV)

Non-Profit Corporation (skip Parts II and III, execute certification in Part IV)

For-Profit Corporation (any type) Limited Liability Company (LLC)

PartnershipLimited Partnership Limited Liability Partnership (LLP)

Other (be specific): ______________________________________________ Part II

The list below contains the names and addresses of all stockholders in the corporation who own 10 percent or more of its stock, of any class, or of all individual partners in the partnership who own a 10 percent or greater interest therein, or of all members in the limited liability company who own a 10 percent or greater interest therein, or of all beneficiaries in an established trust or association who hold a 10 percent or greater interest therein, as the case may be. (COMPLETE THE LIST BELOW IN THIS SECTION)

OR

No one stockholder in the corporation owns 10 percent or more of its stock, of any class, or no individual partner in the partnership owns a 10 percent or greater interest therein, or no member in the limited liability company owns a 10 percent or greater interest therein, or no beneficiary in an established trust or association holds a 10 percent or greater interest therein, as the case may be. (SKIP TO PART IV)

(Please attach additional sheets if more space is needed):

Name of Individual or Legal Entity Address

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Part III DISCLOSURE OF 10% OR GREATER OWNERSHIP IN THE STOCKHOLDERS, PARTNERS

OR LLC MEMBERS LISTED IN PART II

If a bidder has a direct or indirect parent entity which is publicly traded, and any person holds a 10 percent or greater beneficial interest in the publicly traded parent entity as of the last annual federal Security and Exchange Commission (SEC) or foreign equivalent filing, ownership disclosure can be met by providing links to the website(s) containing the last annual filing(s) with the federal Securities and Exchange Commission (or foreign equivalent) that contain the name and address of each person holding a 10% or greater beneficial interest in the publicly traded parent entity, along with the relevant page numbers of the filing(s) that contain the information on each such person. Attach additional sheets if more space is needed.

Website (URL) containing the last annual SEC (or foreign equivalent) filing Page #’s

Please list the names and addresses of each stockholder, partner, beneficiary or member owning a 10 percent or greater interest in any corresponding corporation, partnership and/or limited liability company (LLC) , trust, association, or other legal entity listed in Part II other than for any publicly traded parent entities referenced above. The disclosure shall be continued until names and addresses of every noncorporate stockholder, natural person, and/or and individual partner, and member exceeding the 10 percent ownership criteria established pursuant to N.J.S.A. 52:25-

24.2 has been listed, or is otherwise disclosed that there is no further breakdown of beneficial owners greater than or equal to 10 percent. Attach additional sheets if more space is needed. PLEASE REVIEW THE GENERAL

INSTRUCTIONS AND CONDITIONS SECTION RELEVANT TO THIS FORM.

Stockholder/Partner/Member/Beneficiary and Corresponding Entity Listed in Part II

Address

Part IV Certification

I, being duly sworn upon my oath, hereby represent that the foregoing information and any attachments thereto to the best of my knowledge are true and complete. I acknowledge: that I am authorized to execute this certification on behalf of the bidder/proposer; that the County of Salem is relying on the information contained herein and that I am under a continuing obligation from the date of this certification through the completion of any contracts with County of Salem to notify the County of Salem in writing of any changes to the information contained herein; that I am aware that it is a criminal offense to make a false statement or misrepresentation in this certification, and if I do so, I am subject to criminal prosecution under the law and that it will constitute a material breach of my agreement(s) with the, permitting the County of Salem to declare any contract(s) resulting from this certification void and unenforceable.

Full Name (Print): Title:

Signature: Date:

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EXHIBIT I

MANDATORY EQUAL EMPLOYMENT OPPORTUNITY LANGUAGE

N.J.S.A. 10:5-31 et seq. (P.L. 1975, C. 127) N.J.A.C. 17:27 et seq.

CONSTRUCTION CONTRACTS

During the performance of this contract, the contractor agrees as follows:

The contractor or subcontractor, where applicable, will not discriminate against any employee or applicant for employment because of age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex. Except with respect to affectional or sexual orientation and gender identity or expression, the contractor will take affirmative action to ensure that such applicants are recruited and employed, and that employees are treated during employment, without regard to their age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex. Such equal employment opportunity shall include, but not be limited to the following: employment, up-grading, 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 contractor agrees to post in conspicuous places, available to employees and applicants for employment, notices to be provided by the Public Agency Compliance Officer setting forth provisions of this nondiscrimination clause.

The contractor or subcontractor, where applicable will, in all solicitations or advertisements for employees placed by or on behalf of the contractor, state that all qualified applicants will receive consideration for employment without regard to age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex.

The contractor or subcontractor will send to each labor union, with which it has a collective bargaining agreement, a notice, to be provided by the agency contracting officer, advising the labor union or workers' representative of the contractor's commitments under this act and shall post copies of the notice in conspicuous places available to employees and applicants for employment.

The contractor or subcontractor, where applicable, agrees to comply with any regulations promulgated by the Treasurer, pursuant to N.J.S.A. 10:5-31 et seq., as amended and supplemented from time to time and the Americans with Disabilities Act.

When hiring or scheduling workers in each construction trade, the contractor or subcontractor agrees to make good faith efforts to employ minority and women workers in each construction trade consistent with the targeted employment goal prescribed by N.J.A.C. l7:27-7.2; provided, however, that the Department of LWD, Construction EEO Monitoring Program, may, in its discretion, exempt a contractor or subcontractor from compliance with the good faith procedures prescribed by the following provisions, A, B and C, as long as the Department of LWD, Construction EEO Monitoring Program is satisfied that the contractor or subcontractor is employing workers provided by a union which provides evidence, in accordance with standards prescribed by the Department of LWD, Construction EEO Monitoring Program, that its percentage of active "card carrying" members who are minority and women workers is equal to or greater than the targeted employment goal established in accordance with N.J.A.C. l7:27-7.2. The contractor or subcontractor agrees that a good faith effort shall include compliance with the following procedures:

(A) If the contractor or subcontractor has a referral agreement or arrangement with a union for a construction trade, the contractor or subcontractor shall, within three business days of the contract award, seek assurances from the union that it will cooperate with the contractor or subcontractor as it fulfills its affirmative action obligations under this contract and in accordance with the rules promulgated by the Treasurer pursuant to N.J.S.A. 10:5-31

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et. seq., as supplemented and amended from time to time and the Americans with Disabilities Act. If the contractor or subcontractor is unable to obtain said assurances from the construction trade union at least five business days prior to the commencement of construction work, the contractor or subcontractor agrees to afford equal employment opportunities minority and women workers directly, consistent with this chapter. If the contractor's or subcontractor's prior experience with a construction trade union, regardless of whether the union has provided said assurances, indicates a significant possibility that the trade union will not refer sufficient minority and women workers consistent with affording equal employment opportunities as specified in this chapter, the contractor or subcontractor agrees to be prepared to provide such opportunities minority and women workers directly, consistent with this chapter, by complying with the hiring or scheduling procedures prescribed under (B) below; and the contractor or subcontractor further agrees to take said action immediately if it determines that the union is not referring minority and women workers consistent with the equal employment opportunity goals set forth in this chapter.

(B) If good faith efforts to meet targeted employment goals have not or cannot be met for each construction trade by adhering to the procedures of (A) above, or if the contractor does not have a referral agreement or arrangement with a union for a construction trade, the contractor or subcontractor agrees to take the following actions:

(l) To notify the public agency compliance officer, the Department of LWD, Construction EEO Monitoring Program, and minority and women referral organizations listed by the Division pursuant to N.J.A.C. 17:27-5.3, of its workforce needs, and request referral of minority and women workers;

(2) To notify any minority and women workers who have been listed with it as awaiting available vacancies;

(3) Prior to commencement of work, to request that the local construction trade union refer minority and women workers to fill job openings, provided the contractor or subcontractor has a referral agreement or arrangement with a union for the construction trade;

(4) To leave standing requests for additional referral to minority and women workers with the local construction trade union, provided the contractor or subcontractor has a referral agreement or arrangement with a union for the construction trade, the State Training and Employment Service and other approved referral sources in the area;

(5) If it is necessary to lay off some of the workers in a given trade on the construction site, layoffs shall be conducted in compliance with the equal employment opportunity and non-discrimination standards set forth in this regulation, as well as with applicable Federal and State court decisions;

(6) To adhere to the following procedure when minority and women workers apply or are referred to the contractor or subcontractor:

(i) The contractor or subcontractor shall interview the referred minority or women workers.

(ii) If said individuals have never previously received any document or certification signifying a level of qualification lower than that required in order to perform the work of the construction trade, the contractor or subcontractor shall in good faith determine the qualifications of such individuals. The contractor or subcontractor shall hire or schedule those individuals who satisfy appropriate qualification standards in conformity with the equal employment opportunity and non-discrimination principles set forth in this chapter. However, a contractor or subcontractor shall determine that the individual at least possesses the requisite skills, and experience recognized by a union, apprentice program or a referral agency, provided the referral agency is acceptable to the Department of LWD, Construction EEO Monitoring Program. If necessary, the contractor or subcontractor shall hire or schedule minority and women workers who qualify as trainees pursuant to these rules. All of the requirements, however, are limited by the provisions of (C) below.

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(iii) The name of any interested women or minority individual shall be maintained on a waiting list, and shall be considered for employment as described in (i) above, whenever vacancies occur. At the request of the Department of LWD, Construction EEO Monitoring Program, the contractor or subcontractor shall provide evidence of its good faith efforts to employ women and minorities from the list to fill vacancies.

(iv) If, for any reason, said contractor or subcontractor determines that a minority individual or a woman is not qualified or if the individual qualifies as an advanced trainee or apprentice, the contractor or subcontractor shall inform the individual in writing of the reasons for the determination, maintain a copy of the determination in its files, and send a copy to the public agency compliance officer and to the Department of LWD, Construction EEO Monitoring Program.

(7) To keep a complete and accurate record of all requests made for the referral of workers in any trade covered by the contract, on forms made available by the Department of LWD, Construction EEO Monitoring Program and submitted promptly to the Department of LWD, Construction EEO Monitoring Program upon request.

(C) The contractor or subcontractor agrees that nothing contained in (B) above shall preclude the contractor or subcontractor from complying with the union hiring hall or apprenticeship policies in any applicable collective bargaining agreement or union hiring hall arrangement, and, where required by custom or agreement, it shall send journeymen and trainees to the union for referral, or to the apprenticeship program for admission, pursuant to such agreement or arrangement. However, where the practices of a union or apprenticeship program will result in the exclusion of minorities and women or the failure to refer minorities and women consistent with the targeted county employment goal, the contractor or subcontractor shall consider for employment persons referred pursuant to (B) above without regard to such agreement or arrangement; provided further, however, that the contractor or subcontractor shall not be required to employ women and minority advanced trainees and trainees in numbers which result in the employment of advanced trainees and trainees as a percentage of the total workforce for the construction trade, which percentage significantly exceeds the apprentice to journey worker ratio specified in the applicable collective bargaining agreement, or in the absence of a collective bargaining agreement, exceeds the ratio established by practice in the area for said construction trade. Also, the contractor or subcontractor agrees that, in implementing the procedures of (B) above, it shall, where applicable, employ minority and women workers residing within the geographical jurisdiction of the union.

After notification of award, but prior to signing a construction contract, the contractor shall submit to the public agency compliance officer and the Department of LWD, Construction EEO Monitoring Program an initial project workforce report (Form AA-201) electronically provided to the public agency by the Department of LWD, Construction EEO Monitoring Program, through its website, for distribution to and completion by the contractor, in accordance with N.J.A.C. 17:27-7. The contractor also agrees to submit a copy of the Monthly Project Workforce Report once a month thereafter for the duration of this contract to the Department of LWD, Construction EEO Monitoring Program, and to the public agency compliance officer.

The contractor agrees to cooperate with the public agency in the payment of budgeted funds, as is necessary, for on-the-job and/or off-the-job programs for outreach and training of minorities and women.

(D) The contractor and its subcontractors shall furnish such reports or other documents to the Department of LWD, Construction EEO Monitoring Program as may be requested by the Department of LWD, Construction EEO Monitoring Program from time to time in order to carry out the purposes of these regulations, and public agencies shall furnish such information as may be requested by the Department of LWD, Construction EEO Monitoring Program for conducting a compliance investigation pursuant to N.J.A.C. 17:27-1.1 et seq.

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AFFIRMATIVE ACTION COMPLIANCE NOTICE

N.J.S.A. 10:5-31 et seq. and N.J.A.C. 17:27 et seq.

CONSTRUCTION CONTRACTS

Upon award of a construction contract, the contractor must access Form AA-201, the Initial Project Workforce Report. The Division of Public Contracts Equal Employment Opportunity Compliance has web-enabled Form AA-202, Monthly Project Workforce Report for Construction Contractors.

Vendors and contractors may obtain these forms directly from the Division by accessing the following:

www.state.nj.us/treasury/contract_compliance.

Contractors and vendors are responsible for sending copies of the forms to the County.

Proper completion and submission of these reports shall constitute evidence of the contractor’s compliance with the regulations. Failure to submit these forms may result in the contract being terminated. The contractor also agrees to submit a copy of the Monthly Project Workforce Report, Form AA-202 once a month thereafter for the duration of the contract to the Division and to the County Compliance Officer. After notification of award, but prior to signing a construction contract the EEO/AA evidence must be submitted. The County shall retain the Affirmative Action evidence in the bid file for review by the Division.

All successful Construction Contractors must submit the following as evidence:

1. Complete Form AA-201 (Initial Project Workforce Report).

2. This report must be submitted to the Department of Purchasing after notification of award but prior to signing a contract.

3. The contractor shall submit Form AA-202 (Monthly Project Workforce Report) to the County and to the

Division of Public Contracts Equal Employment Opportunity Compliance once a month thereafter for the duration of the contract.

The undersigned contractor further understands that his/her bid shall be rejected as non-responsive if said contractor fails to comply with the requirements of N.J.S.A. 10:5-31 and N.J.A.C. 17:27.

COMPANY: ____________________________ SIGNATURE: __________________________

PRINT NAME: __________________________ TITLE: ________________________________

DATE: __________________________

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EXHIBIT J

AMERICANS WITH DISABILITIES ACT MANDATORY LANGUAGE

Equal Opportunity for Individuals with Disabilities

The CONTRACTOR and the OWNER do hereby agree that the provisions of Title II of the Americans With Disabilities Act of 1990 (the “Act”) (42 U.S.C. s12101 et seq.), which Prohibits discrimination on the basis of disability by public entities in all services, programs, and activities provided or made available by public entities, and the rules and regulations promulgated pursuant thereunto, are made a part of this contract. In providing any aid, benefit, or service on behalf of the OWNER pursuant to this contract, the CONTRACTOR agrees that the performance shall be in strict compliance with the Act. In the event that the CONTRACTOR, its agents, servants, employees, or subcontractors violate or are alleged to have violated the Act during the performance of this contract, the CONTRACTOR shall defend the OWNER in any action or administrative proceeding commenced pursuant to this Act. The CONTRACTOR shall indemnify, protect, and save harmless the OWNER, its agents, servants, and employees from and against any and all suits, claims, losses, demands, or damages of whatever kind or nature arising out of or claimed to arise out of the alleged violation. The CONTRACTOR shall, at its own expense, appear, defend, and pay any and all charges for legal services and any and all costs and other expenses arising from such action or administrative proceeding or incurred in connection therewith. In any and all complaints brought pursuant to the OWNER’S grievance procedure, the CONTRACTOR agrees to abide by any decision of the OWNER, which is rendered pursuant to, said grievance procedure. If any action or administrative proceeding results in an award of damages against the OWNER or if the OWNER incurs any expense to cure a violation of the ADA which has been brought pursuant to its grievance procedure, the CONTRACTOR shall satisfy and discharge the same at its own expense.

The OWNER shall, as soon as practicable after a claim has been made against it, give written notice thereof to the CONTRACTOR along with full and complete particulars of the claim. If any action or administrative proceeding is brought against the OWNER or any of its agents, servants, and employees, the OWNER shall expeditiously forward or have forwarded to the CONTRACTOR every demand, complaint, notice, summons, pleading, or other process received by the OWNER or its representatives.

It is expressly agreed and understood that any approval by the OWNER of the services provided by the CONTRACTOR pursuant to this contract will not relieve the CONTRACTOR of the obligation to comply with the Act and to defend, indemnify, protect, and save harmless the OWNER pursuant to this paragraph.

It is further agreed and understood that the OWNER assumes no…