Okaloosa County BOCC — February 4, 2014 — Purchasing Forms — reading text

future. Printed Name of Authorized User: Signature of Authorized User: Date: Name of Department: Type of Equipment Requested: CIRCLE ALL THAT APPLY Smart Phone, PDA (Blackberry), Cellular, Push to Talk Radio {Link}, Pager, Air Card APPROVED BY: Department Director’s Signature: Date: Information Systems Department: Date: Requesting Department complete the following information & fax to: Purchasing Dept. @ 850-689-5970 Wireless Communication Device: Mfr Model Serial #: Wireless Telephone #: 58 CONFLICT OF INTEREST DISCLOSURE FORM For purposes of determining any possible conflict of interest, all bidders/proposers, must disclose if any Okaloosa Board of County Commissioner, employee(s), elected officials(s), or if any of its agencies is also an owner, corporate officer, agency, employee, etc., of their business. Indicate either “yes” (a county employee, elected official, or agency is also associated with your business), or “no”. If yes, give person(s) name(s} and position{s) with your business. YES. NO NAME(S) POSITION(S) FIRM NAME: BY (PRINTED): BY (SIGNATURE): TITLE: DATE: ADDRESS: PHONE NO. E-MAIL 59 NO CONTACT CLAUSE The Board has established a solicitation silence policy (No Contact Clause) that prohibits oral and written Communication regarding all formal solicitations for goods and services (formal bids, Request for Proposals, Requests for Qualifications) issued by the Board through the County Purchasing Department. The period commences when the procurement document is received and terminates when the Board approves an award. When the solicitation silence period is in effect, no oral or written communication is allowed regarding the solicitation between prospective bidders/proposers and members of the Board, the County Administrator or members of the Board Approved Review Committee. All questions or requests for information regarding the solicitation must be directed fo the designated Purchasing Representative listed in the solicitation. Any information thought to affect the committee or staff recommendation submitted after bids are due, should be directed to the Purchasing Director or his appointed representative. It shall be the Purchasing Director's decision whether to consider this information in the decision process. Any violation of this policy shall be grounds to disqualify the proposer from consideration during the selection process. All proposers must agree to comply with this policy by signing the following statement and including it with their submittal. I representing Signature Company Name on this day of , 20__hereby agree to abide by the County's “No Contact Clause” and understand violation of this policy shall result in disqualification of my proposal/submittal. 60 SELECTION COMMITTEE MEMBER INSTRUCTIONS You have been selected to serve on a Board-approved Review and Recommendation Committee for services for Okaloosa County. 1. 2. Note: You will be given a copy of all proposals received for this service. You are required to read and review each proposal, make written notes as to the proposal meeting the following criteria: a. Did the response meet the requested format? b. Did the proposal include all required documentation? c. Does this firm seem capable of producing the services requested? Fill out the provided ranking sheet for each firm. At a duly noticed meeting, all Committee Members will discuss the strengths and weaknesses of each firm. No discussion may be conducted between Commitiee Members related to the proposals except during the duly noticed meeting. All Committee Members will submit their signed ranking sheet to the Committee Chair or the Purchasing representative. A consensus ranking will be prepared for attachment to the Board agenda recommendations to be presented at the next Board meeting. Upon approval by the Board, the Purchasing Director shall notify all firms submitting proposals of the Board action. The Board has adopted a No Contact Clause prohibiting contact by potential bidders/proposers from contacting any committee members effective on the date bids/proposals are due. Committee members shall report any violations to the Purchasing Director. Any questions directed to any Committee Member by a proposer should be directed to the Purchasing Director. 61 SOLE SOURCE PURCHASE DATA SHEET Date: PR No.: Requestor: Phone No.: Department/Division: Item Description: Requesting Department's Suggested Vendor: Vendor's Address: Vendor's Telephone No.: Point of Contact: Sole Source Justification: Requesting Department Director Signature Date REVIEW BY PURCHASING DEPARTMENT VERIFY IF OTHER SOURCES OF SUPPLY MEETS THIS NEED Vendor #1 Contact: Phone No.: Vendor #2 Contact: Phone No.: Vendor #3 Contact: Phone No.: Buyer Comments: Signature of Buyer Who Reviewed Date Purchasing Services Coordinator Comments: Purchasing Services Coordinator Signature Date PURCHASING MANUAL - SOLE SOURCE DETERMINATION Comments: Approve: Disapprove: Amount of Purchase: Date: Purchasing Director Signature Date OKALOOSA COUNTY PURCHASING CARD EXPENDITURE REPORT Below is an account of all Purchasing Card expenditures for: Name of Employee/Department Purchasing Card Number For the month of DESCRIPTION OF ITEMS DATE | VENDOR | PURCHASED AMOUNT DEPT. ACCOUNT NUMBER __| NUMBER PURPOSE OF TRANSACTION DATE GOODS/ SERVICES RECEIVE! | HEREBY CERTIFY THAT ALL PURCHASES CONTAINED HEREIN WERE FOR OFFICIAL OKALOOSA COUNTY BUSINESS, WERE MADE IN ACCORDANCE WITH RULES AND DIRECTIVES, AND THAT | HAVE REVIEWED THIS LOG AND IT CORRECTLY REFLECTS THE CARD RECEIPTS ENCLOSED. SIGNATURE OF CARDHOLDER DATE SIGNATURE OF REVIEWER DATE DELIVER TO: OKALOOSA COUNTY COURTHOUSE - FINANCE OFFICE, 302 N. Wilson Street, Suite 203 Crestview FL 32536 63 LOST OR STOLEN PURCHASING CARD REPORTING FORM TO: PURCHASING DEPARTMENT FAX: 850-689-5037 FROM: PHONE: URGENT MESSAGE PLEASE DELIVER THIS FACSIMILE IMMEDIATELY EMPLOYEE NAME: PURCHASING CARD NO.: DATE CARD WAS LOST/STOLEN: (If unknown, report today’s date} TIME CARD WAS LOST/STOLEN: (If unknown, report time this form was completed)) LAST KNOWN LOCATION OF CARD: LAST KNOWN TIME CARD WAS USED: (indicate location and date of last charge} REMARKS: 64 PURCHASING CARD MAINTENANCE FORM DATE: DEPARTMENT: PHONE $ AMOUNT EMPLOYEE'S NAME NUMBER CARD NUMBER REQUESTED MAINTENANCE REQUESTED (Circle as needed} [] ADD CARDHOLDER {Fill out above) CJ DELETE/CANCEL ACCOUNT (Account #) [-] _ RAISE/LOWER LIMIT (Existing amount) [] OTHER (explain) Authorized By. (Department Director) Fax Back To: 689-5037 (Purchasing Department) 65 Approved by: Cardholder Signature: Company Name: Cardholder Name: Cardholder Account Number: OKALOOSA COUNTY BOARD OF COUNTY COMMISSIONERS PURCHASING CARD DISPUTE FORM Statement Date Transaction Date Merchant Name/Description Amount Posting Date Reference Number Check the description most appropriate to your dispute. If you have any questions, contact 1. 10. Alteration of Amount: The amount of the sales draft has been altered from $ to § (Please include copy of sales draft) Unauthorized Mail or Phone Order: | certify the charge listed above was not authorized by me or any person authorized by me fo use this account. | have not ordered merchandise by phone or mail or received goods and services as represented above, Cardholder Dispute: I did participate in the above transaction: however, | dispute the entire charge, or a portion, in the amount of §. because: Credit Not Received: The merchant has issued me a credit slip for the transaction listed above; however, the credit has not been posted to my account. The date on the voucher is between 30 and 90 days ald. (Please include a copy of the credit voucher.) Imprinting of Multiple Slips: The above transaction represents multiple billing to my account. | only authorized one charge from this merchant for $ - !am still in possession of my card. Merchandise Not Received: My account has been charged for the above transaction, but | have not received this merchandise. | have contacted the merchant. Merchandise Not Received: My account has been charged for the above transaction, but | have since contacted this merchant and canceled the order. | will refuse delivery should the merchancise still Merchandise Returned: My account has been charged for the transaction listed above, but the merchandise has been returned. Provide a description of the circumstances. (Please include postal Inadequate Description/Unrecognized Charge: i do not recognize this charge. Please supply a copy of the sales draft for my review. 1am no longer disputing this charge. 66 OKALOOSA COUNTY PURCHASING CARD AGREEMENT , agree to the following regarding my use of the Purchasing Card: {Print Name) | understand that | am being entrusted with a valuable tool and will be financially obligating Okaloosa County and will strive to obtain the best value for the taxpayers of Okaloosa County. | understand that under no circumstances will | use the Purchasing Card to make personal purchases. Willful intent to use the Purchasing Card for personal use may result in disciplinary actions, including termination of employment. | will follow the established procedures for using the Purchasing Card. Failure to do so may result in the revocation of my use privileges or other disciplinary actions. Additionally, | will follow all County purchasing requirements. | have read the Purchasing Card provisions contained in the Purchasing Manual and understand the requirements for using the Purchasing Card. | agree that should | violate the terms of this Agreement and use the Purchasing Card for personal use or gain, | will reimburse the County for all incured charges and any fees related to the collection of those charges. Employee Name (Print) Employee Signature/Date 67 BID ATTACHMENTS The following are requirements that shall be included in all bid specifications (Special Conditions section) for projects that are funded through/by the U.S. Department of Transportation, Federal Transit Administration. Additional FTA requirements that may be required can be found in the matrix located in Appendix A. Okaloosa County reserves the right to reject any/all bids that are submitted incomplete or without these documents. 1. 10. oN BF OH FWD Buy America Bus Testing Lobbying Clean Air Civil Rights Bid Protests Government Debarment and Suspension Fraud The Purchasing Director has the authority and responsibility to ensure Federal requirements are met regarding all procurements of goods and services utilizing FIA Funds. That person will also have the ability to stop any procurement activity if it conflicts with Federal procurement practices. The Okaloosa County Coordinated Transportation Office shall ensure that all required portions of the Uniform Administrative Requirements for Grants & Cooperative Agreements (49CFR-Part 18 & Circular 4220 are complied with. The Purchasing Department & Okaloosa Coordinated Transit will maintain current copies of the above documents and familiarize themselves with the requirements. Okaloosa Coordinated Transit shall maintain a written record of all purchases utilizing FTA funds showing the purpose of the expenditure. 68 FEDERAL TRANSIT ADMINISTRATION REQUIREMENTS UNDER 49 CFR, PARTS 18 AND 19, AND CIRCULAR 4220 BUY AMERICA - The contractor agrees to comply with 49 U.S.C. 5323(j} and 49 CFR Part 661 which provide that Federal funds may not be obligated unless steel, iron, and manufactured products used in FTA-funded projects are produced in the United States, unless a waiver has been granted by FTA or the product is subject to a general waiver. General waivers are listed in 49 CFR 661.7 and include final assembly in the United States for 15 passenger vans and 15 passenger wagons produced by Chrysler Corporation, microcomputer equipment, software, and small purchases