Standard Affirmation & Disclosure Form_fillable PDF Form.pdf
PDF 267 KB Posted
- Solicitation number
- SRC0000018267
- Issued by
- Columbiana County, Ohio
About this file
The document is an Affirmation and Disclosure Form related to a state and local contract opportunity in Ohio. The contract opportunity is for the removal of surface debris, including household trash, empty steel drums, and approximately 300 scrap tires, from an illegal dumping site located in Columbiana County near the Beaver Local High School Football Field. The project is part of the Ohio Department of Natural Resources' H2Ohio Rivers Program, which aims to improve the health of Ohio's rivers and streams. The technical proposal should address the company's history, relevant experience, proposed timeline, and plan to minimize site disturbance. Bidders are required to attend an optional site visit on April 11, 2024, at 1:00 pm.
The cost proposal should be submitted separately. Failure to request a site visit will not be a valid reason to be released from the contract. The contract will be awarded to the successful bidder. The document also includes an Affirmation and Disclosure Form, which requires the contractor and any subcontractors to perform all services within the United States and not allow state data to be accessed or stored remotely outside the United States without a waiver.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Services Agreement Template (Non-Federal Funds)_for OhioBuys.docx | DOCX document | |
| Standard_T_C_04-10-23.pdf | ||
| OhioBuys_Fact_Sheet_for_Bidders_Suppliers (2).pdf | ||
| H2Ohio_RFP _BeaverLSD_TiresTrash.pdf |
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Text version
Version 2/20 Page 1 of 2
AFFIRMATION AND DISCLOSURE FORM
By the signature affixed hereto, the Contractor affirms and understands that if awarded a contract, both the Contractor and any of its subcontractors shall perform no services requested under this Contract outside of the United States, nor allow State data to be sent, taken, accessed, tested, maintained, backed-up, stored or made available remotely (located) outside of the United States unless a duly signed waiver from the State has been attained.
The Contractor shall provide all the name(s) and location(s) where services under this Contract will be performed and where data is located in the spaces provided below or by attachment. Failure to provide this information may result in no award. If the Contractor
1. Principal location of business of Contractor:
(Address) (City, State, Zip)
Name/Principal location of business of subcontractor(s):
(Name) (Address, City, State, Zip)
2. Location where services will be performed by Contractor:
(Address) (City, State, Zip)
Name/Location where services will be performed by subcontractor(s):
Version 2/20 Page 2 of 2
3. Location where state data will be located, by Contractor:
(Address) (Address, City, State, Zip)
Name/Location(s) where state data will be located by subcontractor(s):
Contractor also affirms, understands and agrees that Contractor and its subcontractors are under a duty to disclose to the State any change or shift in location of services performed by Contractor or its subcontractors before, during and after execution of any contract with the State. Contractor agrees it shall so notify the State immediately of any such change or shift in location of its services. The State has the right to immediately terminate the contract, unless a duly signed waiver from the State has been attained by the Contractor to perform the services outside the United States.
On behalf of the Contractor, I acknowledge that I am duly authorized to execute this Affirmation and Disclosure Form and have read and understand that this form is a part of any Contract that Contractor may enter into with the State and is incorporated therein.
By: __________________________________ Contractor
Print Name: ___________________________
Title: __________________________________
Date: __________________________________
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