splash_pad_bid_forms.pdf

BID PROPOSAL SUBMISSION FORMS

CAPOUSE AVE PARK SPLASH PAD INSTALLATION

NAME OF BIDDER: _____________________________________________

BID SUBMISSION FORMS

- Contractor Information Form

- Statement of Bidder’s Qualifications

- Contractor Bid Proposal Form o Itemized Bid Form o Summary Bid Forms

- Bid Bond (10%)

- Contractor Schedule

- Certificate of Non-Segregated Facilities

- Non-Collusion Affidavit

- Non-Discrimination/Equal Opportunity/Sexual Harassment Policy

- Employment Verification Form

- Certification of Non-Employment Illegal Alien Labor

- Certificate of Bidder Regarding Equal Employment Opportunity

All Bidders are required to submit these Bid Submission Forms

CONTRACTOR INFORMATION FORM

CONTRACTOR INFORMATION FORM

NAME OF FIRM ___________________________________________________________

ADDRESS _________________________________________________________________

AUTHORIZED SIGNATURE _________________________________________________

TYPED NAME AND TITLE __________________________________________________

PHONE NO.____________________________ FAX_____________________________

EMAIL ____________________________________________________________________

EMERGENCY (24-HOUR) PHONE NO. ________________________________________

U.S. TREASURY EMPLOYER’S IDENTIFICATION NO. __________________________

SUBCONTRACTORS (NAME/TASK)? [LIST, IF APPLICABLE (MUST BE APPROVED BY CITY):

NOTE: Firms must use their FULL LEGAL name. Generally, a corporation’s name must end with a suffix indicating the corporate statue of that business (i.e., Inc., Co., Corp., etc.). Trade names may be indicated by individuals or corporations with the individual or corporation name followed by “t/a” (trading as) or “d/b/a”

(doing business as), respectively. Failure to use your FULL LEGAL name may be cause for rejection of the bid.

STATEMENT OF BIDDER’S QUALIFICATIONS

STATEMENT OF BIDDER’S QUALIFICATIONS

All questions must be answered in a clear and comprehensive manner. If necessary, questions may be answered on separate attached sheets. The Bidder may submit any additional information he/she desires that is project specific.

1. General character of work performed by your company.

2. Have you ever failed to complete any work awarded to you? Have you ever defaulted on a contract? If so, where and why?

3. State your experience in construction work similar in importance to this project. Specifically, do you have experience working with ADA accessible routes and recreational facilities? If yes, please list a few projects. Have you worked in the City of Scranton before?

4. Background and experience of the project manager and/or foreman.

5. List two references, with contact information, from comparable projects.

The undersigned hereby authorizes and requests any person, firm, or corporation to furnish any information requested by The City of Scranton in verification of the recitals comprising this statement of Bidder’s Qualifications.

Name of Company _____________________________

By: _____________________________

Date: _______________________ Title: _____________________________

BID PROPOSAL

CONTRACTOR BID PROPOSAL

CAPOUSE AVE PARK RENOVATION PROJECT

The undersigned, having familiarized themselves with the existing conditions on the preserve that may impact the cost of the work and with the Contract Documents (including the Construction

Drawings, the Project Manual, Addenda (if any), the Invitation to Bidders, the Instructions to Bidders, the General Conditions Part I, the General Conditions Part II, the Attachments to General Conditions, and the Technical Specifications), hereby proposes to furnish all supervision, technical personnel, labor, materials, machinery, tools, equipment, and services, including water, utility and transportation services, and other facilities and services necessary to perform and complete all work required for construction of the improvements embraced in the Plans and Specifications for The Capouse Avenue

Park Splash Pad Installation and all incidental work in strict accordance with the Contract

Documents by end of September 2025.

BASE BID PRICE OF ($______________________________________________)

___________________________________________________________ Dollars

1. In submitting this bid, the Bidder understands that The City of Scranton reserves the right to reject any or all bids or to waive any informality in the bidding. If written notice of the acceptance of this Bid is mailed or delivered to the undersigned within sixty (60) days after the opening thereof, or at any time thereafter before this Bid is withdrawn, the undersigned agrees to execute and deliver the Contract Agreement in the form prescribed by The City of

Scranton, within 10 days. The Bidder understands that they must furnish Workers

Compensation Insurance, the required Public Liability Insurance, the required Builders

Risk/All Risk Insurance (if applicable), the required Performance Bond, Labor and Material

Payment Bond and Maintenance Bond within ten (10) days after the Agreement is presented to him for signature.

2. Attached and included hereto submission are the following forms:

a. Bid Forms / Summary Bid Form

b. Bid Bond - Security in the sum of ____________________________ dollars

($_____________), in the form of a __________________.

c. Contractor Schedule

d. Certification of Non-Segregated Facilities

e. Non-Collusion Affidavit of Prime Bidder

f. Non-Discrimination / Sexual Harassment Clause

3. The undersigned represents that he is in receipt of the following number of Addenda (if no

Addenda have been issued, insert the word “none” in the following space):

Addenda # ____________ Addenda # ____________

Addenda # ____________ Addenda # ____________

BID PROPOSAL

I. WHEN THE PROSPECTIVE CONTRACTOR IS AN INDIVIDUAL:

If the Prospective Contractor is an individual trading under his owner and his exact post office address must be given. If one other than the owner signs this proposal, then a notarized certificate of authority signed by the owner must accompany this proposal.

_____________________________ _______________________(SEAL)

Witness Prospective Contractor

Address: __________________________________________________________

Trading as: ________________________________________________________

II. WHEN THE PROSPECTIVE CONTRACTOR IS A PARTNERSHIP:

If the Prospective Contractor is a firm or partnership trading under an individual of fictitious name, this proposal must be signed by one or more partners and the exact names and post office addresses of the members of the firm or partnership must be included. If one other than a partner signs this proposal, then a notarized certificate of authority signed by all the partners must accompany this proposal.

Witness Partner

Witness Partner

III. *WHEN THE PROSPECTIVE CONTRACTOR IS A CORPORATION:

If the Prospective Contractor is a corporation, the proposal must be signed by the president or vice-president, or by an individual whose notarized certificate of authority to execute must accompany this proposal together with the names, titles, and business addresses of the president, secretary, and treasurer, which must appear on the said certificate.

Secretary President

(CORPORATE SEAL)

*The _______________ is a corporation organized and existing under the laws of the State of

_______________ and has been granted a certificate of authority to do business in Pennsylvania, required by the Business Corporation Law, approved May 5, 1933, P. L. 364, as amended.

BID FORMS

City of Scranton Capouse Ave Park Splash Pad Installation

Scope of Work and Itemized Bid Form

The City of Scranton is looking to contract with a Vortex-brand certified installer for the installation of a splash pad at Capouse Avenue Park. The City has already purchased and is in possession of the splash pad components as manufactured by Vortex.

A general list of what will be required from this contractor is listed below:

The splash pad contractor will be responsible for:

1. Installation of all splash pad spray features, drains, and associated water supply and drainage plumbing, electrical wiring, connections, as depicted on the plans.

2. Installation of all associated site features, such as debris trap and water containment system, and associated plumbing, electrical wiring, connections.

3. Related concrete placement (splash pad surface itself, as well as slabs to anchor spray features, water containment system, etc.).

4. Installation of all components within the mechanical room, and associated plumbing, electrical wiring, connections to equipment within the room as well as to equipment located outside of the building.

5. All wiring from main panel/breaker box to various splash pad control panels, etc.

6. Connections from main building water supply to splash pad components.

7. All other work indicated “by installer” on the plan drawings.

Itemized Bid Form:

Earthwork

1. Excavation as needed to accommodate installation of all splash pad components, including but not limited to water containment system, debris trap/diverter, splash pad drains and drain lines, water supply lines, spray features, electrical lines, etc.

○ PRICE: $_________________________

Splash Pad Component Installation

2. Splash Pad Equipment Transportation: Transportation of Vortex Splash Pad components from stored location at Weston Field House (982 Providence Rd, Scranton, PA 18508) to Capouse Ave Park site (approx. address 1343 Capouse Ave, Scranton, PA 18509).

○ PRICE: $_________________________

3. Vortex Splash Pad Component Installation: Installation of all Splash Pad components, including but not limited to spray heads/fixtures, water supply piping, drains and drainage piping, electrical wiring, control components, filtration and disinfection equipment, etc. as depicted on plans prepared by Vortex. This includes all Splash

Pad system components located on the site as well as those to be located within the building's mechanical room. Installation to be performed by a Vortex-certified installer. Vortex equipment to be provided by the City.

○ PRICE: $_________________________

4. Splash Pad Concrete Pad: Pour concrete splash pad and 5' concrete perimeter splash zone; 6" depth, rebar framework, spray head protection; Oversight provided by

Vortex-certified installer

○ PRICE: $_________________________

5. Splash Pad Appurtenance Subbase & Aggregate Bedding and Backfill: Place and tamp/compact stone bedding and backfill (2B aggregate or as otherwise indicated) where indicated, including but not limited to beneath proposed splash pad, water containment system and debris trap; inclusive of geotextile fabric. Provide sand bedding and backfill around water pipes and drain lines.

○ PRICE: $_________________________

6. Concrete Base Slabs and Anchors: Install concrete slabs beneath the water containment system, debris trap, spray heads, etc., along with any required anchors, as depicted on plans prepared by Vortex.

○ PRICE: $_________________________

7. Miscellaneous Vortex System Connections to Site Utilities: Includes installation of 1" make-up water line from site service line to Water Containment System, and connection of Debris Trap and Water Containment System to Catch Basin CB-5 (CB-

5 to be installed by others)

○ PRICE: $_________________________

TOTAL PRICE: $__________________

BID BOND

SUMMARY BID FORM

BASE BID (Total from Itemized Bid Sheets; Insert Amount in Words & Numbers)

THE BIDDER AFFIRMS AND DECLARES:

1. That the Bidder is of lawful age and that no other person, firm, corporation, or joint venture has any interest in this Bid or in the Contract proposed to be entered into.

2. That this Bid is made without any understanding, agreement or connection with any other person, firm, corporation, or joint venture making a Bid for the same purposes, and is in all respects fair and without collusion or fraud.

3. That the Bidder has carefully examined the site of the work, and that from his own investigations, he has satisfied himself as to the nature and location of the work, the character, quality, and quantity of materials and the kind and extent of equipment and other facilities needed for the performance of the work, the general and local conditions and all difficulties to be encountered, and all other items which may, in all ways, affect the work or its performance.

4. The undersigned, as Bidder, also declares that he has carefully examined and fully understands all the component parts of the Contract Documents and agrees that he will execute the Contract and completely perform the work in strict accordance with the terms of the Contract and the Contract Documents therein referred to.

EXCEPTIONS:

All exceptions taken to the specifications contained in this document must be clearly indicated in the space provided in the space below. Unless noted as an exception, the bidder will be held responsible for providing each component or standard called for in the construction documents.

The City of Scranton retains the exclusive right to approve or reject any exception taken to the specifications contained in this bid. It is hereby agreed that if this bid is rejected due to an exception taken to a specification by the bidder, the rejection of the bid will be final and no further action may be taken.

Do you claim any exception to any specifications in this Bid? _________________________

COMPANY NAME

AUTHORIZED SIGNATURE

TELEPHONE NUMBER E-MAIL ADDRESS

KNOW ALL PERSONS BY THESE PRESENTS, that we the undersigned

______________________ as PRINCIPAL, and _________________________________ as

SURETY are held and firmly bound unto THE CITY OF SCRANTON, hereinafter called “THE

CITY OF SCRANTON”, in the penal sum of

________________________________________________ Dollars ($_____________________) lawful money of the United States, for the payment of which sum will and truly to be made, we bind ourselves, our heirs, executors, administrators, successors, and assigns, jointly and severely, firmly by these presents.

THE CONDITION OF THIS OBLIGATION IS SUCH, that whereas the Principal has submitted the accompany bid, dated _______________________, 2025, for The Capouse Avenue Park

Renovation Project

NOW, THEREFORE, if the Principal shall not withdraw said Bid within thirty (30) days after the said opening, and shall within the period specified therefore, or if no period be specified, then within ten (10) days after the prescribed forms are presented to him for signature, enter into a written Contract with THE CITY OF SCRANTON in accordance with the Bid accepted, and give bond with good and sufficient surety or sureties, as may be required, for the faithful performance and proper fulfillment of such Contract; or in the event of the withdrawal of said Bid within the period specified, or in the failure to enter in to such Contract and give such bond within the time specified, if the Principal shall pay THE CITY OF SCRANTPN may procure the required work or supplies or both, if the latter be in excess of the former, then the above obligation shall be void and of no effect, otherwise to remain in full force and virtue.

IN WITNESS WHEREOF, the above-bounded parties have executed this instrument under their several seals this __________ day of _________, 2025, the name and corporate seal of each corporate party being hereto affixed, and these presents signed by its undersigned representative, pursuant to authority of its governing body.

INDIVIDUAL OR PARTNERSHIP PRINCIPALS

_________________________(SEAL)

_________________________(SEAL)

In the presence of: _________________________(SEAL)

________________________ _________________________(SEAL)

CORPORATE PRINCIPAL

ATTEST: _________________________

_________________________ _________________________(SEAL)

SURETY

ATTEST: _________________________

_________________________ _________________________(SEAL)

Countersigned:

By: _____________________

Attorney-in-Fact, State of __________________

CERTIFICATE AS TO CORPORATE PRINCIPAL

I, _______________________, certify that I am the Secretary of the Corporation named as Principal in the within bond; that _________________

__________________________, who signed the said bond on behalf of the Principal was then ___________________ of said Corporation; that I know his signature, and his signature thereto is genuine; and that said bond was duly signed, sealed and attested to for and in behalf of said corporation by authority of his governing body.

Title: __________________________

(CORPORATE SEAL)

CONTRACTOR SCHEDULE

CONTRACTOR SCHEDULE

To assure your understanding of the project, please provide below your potential project construction schedule that highlights major milestones with tentative completion dates for the major features, for example spray fixture installation, splash pad plumbing, mechanical room equipment installation, installation of splash pad concrete, and completion of work. Substantial completion shall be by end of September 2025.

CERTIFICATE OF NON-SEGREGATED FACILITIES

CERTIFICATE OF NON-SEGREGATED FACILITIES

We, __________________________________________________________(Company) Certify that we do not and will not maintain or provide for our employees any segregated facilities at any of our establishments, and that we do not and will not permit our employees to perform their services at any location, under our control, where segregated facilities are maintained. We understand and agree that breach of this certification is a violation of Equal Opportunity clause required by Executive Order 11246, amended.

As used in this certification, the term "segregated facilities” means any waiting rooms, work areas, rest rooms and wash rooms, restaurants and other eating areas, time clocks, locker rooms and other storage or dressing areas, parking lots, drinking fountains, recreation or entertainment areas, transportation and housing facilities provided for employees which are segregated by explicit directive or are in fact segregated on the basis of race, creed, color, or national origin, because of habit, local custom or otherwise.

We further agree that (except where we have obtained identical certifications from proposed Subcontractors for specific time periods) we will obtain identical certifications from proposed Subcontractors prior to the award of subcontracts exceeding $10,000 which are not exempt from the provisions of the Equal Opportunity clause; that we will retain such certification in our files; and that we will forward the following notice to such proposed Subcontractors (except where the proposed Subcontractors have submitted identical certifications for specific time periods).

NOTICE TO PROSPECTIVE SUBBUILDERS OF REQUIREMENT FOR CERTIFICATION OF

NON-SEGREGATED FACILITIES. A certification of Non-segregated facilities as required by the 9 May 1967 order on Elimination of Segregated Facilities, by the Secretary of Labor (32 Fed. Reg. 7439, 19 May 1967), must be submitted from the provisions either for each subcontract or for all subcontracts during a period (i.e. quarterly, semi-annually, or annually).

NOTE: Whoever knowingly and willfully makes any false, fictitious or fraudulent representation may be liable to criminal prosecution under 18 U.S.C. 1001.

(Name of Company)

By: _____________________________

Date: _______________________ Title: _____________________________

NON-COLLUSION AFFIDAVIT

NON-COLLUSION AFFIDAVIT

STATE OF ______________________________:

COUNTY OF ____________________________:

I state that I, _______________________________ of __________________________

(Name) (Name of Firm) am authorized to make this affidavit on behalf of my firm, and its owners, directors, and officers. I am the person responsible in my firm for the price(s) and the amount of this proposal, and the preparation of the proposal.

I state that:

1. I am fully informed respecting the preparation and contents of the attached Bid and of all pertinent circumstances respecting such Bid;

2. Such Bid is genuine and is not a collusive or sham Bid;

3. Neither the said Bidder nor any of its officers, partners, owners, agents, representatives, employees or parties in interest, including this affiant, has in any way colluded, conspired, connived, or agreed, directly or indirectly with any other Bidder, firm or person to submit a collusive or sham Bid in connection with the Contract for which the attached Bid has been submitted or to refrain from bidding in connection with such Contract, or has in any manner, directly or indirectly, sought by agreement or collusion or communication or conference with any other bidder, firm or person to fix the price or prices in the attached Bid or of any other bidder, or to secure through any other bidder, or to fix any overhead, profit or cost element of the bid price or the bid price of any other bidder, or to secure through any collusion, conspiracy, connivance or unlawful agreement any advantage against The City of Scranton or any person interested in the proposed contract; and

4. The price or prices quoted in the attached Bid are fair and proper and are not tainted by a collusion, conspiracy, connivance or unlawful agreement on the part of the Bidder or any of its agents, representatives, owners, employees, or parties in interest, including this affiant.

(signed)_____________________________

(title) ______________________________

Subscribed and sworn to before me this _____ day of _______________, 2025

(signature)

NONDISCRIMINATION / EQUAL OPPORTUNITY / SEXUAL HARASSMENT CLAUSE

NONDISCRIMINATION / EQUAL OPPORTUNITY / SEXUAL

HARASSMENT CLAUSES / POLICY

Nondiscrimination and equal opportunity are the policy of the Commonwealth and The City of Scranton in all its decisions program, and activities. The purpose is to achieve the aims of the United States and

Pennsylvania Constitutions. Executive Order 1972-1, the Pennsylvania Human Relations Act, Act of

October 27, 1955, (P.L. 744), as amended, (43 P.S. 951, et. seq.), and (43 P.S. 153), by assuring that all persons are accorded equal employment opportunity without regard to race, color, religious creed, handicap, ancestry, national origin, age, or sex.

Sexual harassment includes unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexually harassing nature, when: (1) submission to the harassment is made either explicitly or implicitly a term or condition of employment; (2) submission to or rejection of the harassment is used as the basis for employment decisions affecting the individual; or (3) the harassment has the purpose or effect of unreasonably interfering with an individual’s work performance or creating an intimidating, hostile, or offensive working environment. It is the policy of The City of Scranton that all Township-owned and operated workplaces, including recreational facilities, are free from sexual harassment. Because of The City of Scranton’s strong disapproval of offensive or inappropriate sexual behavior at workplaces, any contractor hired by The City of Scranton must also assure that all of their employees avoid any action or conduct which could be viewed as sexual harassment.

During the term of this contract, the Contractor agrees as follows:

5. In the hiring of any employee(s) for the manufacture of supplies, performance of work, or any other activity required under the grant agreement or any subgrant agreement, contract, or subcontract, the Grantee, a subgrantee, a contractor, a subcontractor, or any person acting on behalf of the Grantee shall not discriminate by reason of race, gender, creed, color, sexual orientation, gender identity or expression, or in violation of the

Pennsylvania Human Relations Act (PHRA) and applicable federal laws, against any citizen of this commonwealth who is qualified and available to perform the work to which the employment relates.

6. The Grantee, any subgrantee, contractor or any subcontractor or any person on their behalf shall not in any manner discriminate by reason of race, gender, creed, color, sexual orientation, gender identity or expression, or in violation of the PHRA and applicable federal laws, against or intimidate any of its employees.

7. Neither the Grantee nor any subgrantee nor any contractor nor any subcontractor nor any person on their behalf shall in any manner discriminate by reason of race, gender, creed, color, sexual orientation, gender identity or expression, or in violation of the PHRA and applicable federal laws, in the provision of services under the grant agreement, subgrant agreement, contract or subcontract.

8. Neither the Grantee nor any subgrantee nor any contractor nor any subcontractor nor any person on their behalf shall in any manner discriminate against employees by reason of participation in or decision to refrain from participating in labor activities protected under the Public Employee Relations Act, Pennsylvania Labor

Relations Act or National Labor Relations Act, as applicable and to the extent determined by entities charged with such Acts’ enforcement, and shall comply with any provision of law establishing organizations as employees’ exclusive representatives.

9. The Grantee, any subgrantee, contractor or any subcontractor shall establish and maintain a written nondiscrimination and sexual harassment policy and shall inform their employees in writing of the policy.

The policy must contain a provision that sexual harassment will not be tolerated and employees who practice it will be disciplined. Posting this Nondiscrimination/Sexual Harassment Clause conspicuously in easily-accessible and well-lighted places customarily frequented by employees and at or near where the grant services are performed shall satisfy this requirement for employees with an established work site.

NONDISCRIMINATION / EQUAL OPPORTUNITY / SEXUAL HARASSMENT CLAUSE

10. The Grantee, any subgrantee, contractor or any subcontractor shall not discriminate by reason of race, gender, creed, color, sexual orientation, gender identity or expression, or in violation of the PHRA and applicable federal laws, against any subgrantee, contractor, subcontractor or supplier who is qualified to perform the work to which the grant relates.

11. The Grantee and each subgrantee, contractor and subcontractor represents that it is presently in compliance with and will maintain compliance with all applicable federal, state, and local laws and regulations relating to nondiscrimination and sexual harassment. The Grantee and each subgrantee, contractor and subcontractor further represents that it has filed a Standard Form 100 Employer Information Report (“EEO-1”) with the

U.S. Equal Employment Opportunity Commission (“EEOC”) and shall file an annual EEO-1 report with the

EEOC as required for employers’ subject to Title VII of the Civil Rights Act of 1964, as amended, that have

100 or more employees and employers that have federal government contracts or first-tier subcontracts and have 50 or more employees. The Grantee, any subgrantee, any contractor or any subcontractor shall, upon request and within the time periods requested by the Commonwealth, furnish all necessary employment documents and records, including EEO-1 reports, and permit access to their books, records, and accounts by the granting agency and the Bureau of Diversity, Inclusion and Small Business Opportunities for the purpose of ascertaining compliance with the provisions of this Nondiscrimination/Sexual Harassment Clause.

12. The Grantee, any subgrantee, contractor or any subcontractor shall include the provisions of this

Nondiscrimination/Sexual Harassment Clause in every subgrant agreement, contract or subcontract so that those provisions applicable to subgrantees, contractors or subcontractors will be binding upon each subgrantee, contractor or subcontractor.

13. The Granter’s and each subgrantee’s, contractor’s and subcontractor’s obligations pursuant to these provisions are ongoing from and after the effective date of the grant agreement through the termination date thereof. Accordingly, the Grantee and each subgrantee, contractor and subcontractor shall have an obligation to inform the commonwealth if, at any time during the term of the grant agreement, it becomes aware of any actions or occurrences that would result in violation of these provisions.

14. The commonwealth may cancel or terminate the grant agreement and all money due or to become due under the grant agreement may be forfeited for a violation of the terms and conditions of this

Nondiscrimination/Sexual Harassment Clause. In addition, the granting agency may proceed with debarment or suspension and may place the Grantee, subgrantee, contractor, or subcontractor in the Contractor

Responsibility File.

Based on Management Directive 215.16 Amended (08/02/18)

DCNR-2022-Gen, Gen-GPM – 1 Rev. 8/18

DATE: ___________________________

(NAME OF CONTRACTOR)

BY ______________________________

TITLE ___________________________

COMMONWEALTH OF PENNSYLVANIA

PUBLIC WORKS EMPLOYMENT VERIFICATION FORM

Date _______________________

Business or Organization Name (Employer)_________________________________________________

Address _____________________________________________________________________________

City _____________________________________ State_____________ Zip Code ________________

Contractor Subcontractor (check one)

Contracting Public Body _______________________________________________________________

Contract/Project No ___________________________________________________________________

Project Description ____________________________________________________________________

Project Location ______________________________________________________________________

As a contractor/subcontractor for the above referenced public works contract, I hereby affirm that as of the above date, our company is in compliance with the Public Works Employment Verification Act (‘the Act’) through utilization of the federal E Verify Program (EVP) operated by the United States Department of Homeland Security. To the best of my/our knowledge, all employees hired post January 1, 2013 are authorized to work in the United States.

It is also agreed to that all public works contractors/subcontractors will utilize the federal EVP to verify the employment eligibility of each new hire within five (5) business days of the employee start date throughout the duration of the public works contract. Documentation confirming the use of the federal EVP upon each new hire shall be maintained in the event of an investigation or audit.

I, _________________________, authorized representative of the company above, attest that the information contained in this verification form is true and correct and understand that the submission of false or misleading information in connection with the above verification shall be subject to sanctions provided by law.

Authorized Representative Signature admin Typewritten text