Fort Walton Beach Council agenda — 12-13-11 regular — reading text

Name: Name: Contact: Contact: Address: Address: Telephone: Telephone: Facsimile: Facsimile Name: Name: Contact: Contact: Address: Address: Telephone: Telephone: Facsimile: Facsimile Page 7 of 37 Packet Pg. 43  NO BID" RESPONSE TO INVITATION TO BID IF YOU ARE NOT SUBMITTING A BID, PLEASE PROVIDE THE INFORMATION BELOW AND RETURN THIS FORM BEFORE THE SCHEDULED BID OPENING DATE TO: Purchasing Agent City Of Fort Walton Beach 105 Miracle Strip Parkway SW Fort Walton Beach, F132548 Or by fax to ( 850) 833 -9643 FAILURE TO RESPOND TO THREE ( 3) CONSECUTIVE BIDS MAY RESULT IN YOUR COMPANY BEING DELETED FROM THE CITY' S BIDDER' S LIST. We have received your invitation to bid for FULL EJECT FRONT LOADER REFUSE TRUCK, ITB# 12 -003, Opening at 2: 30 PM, CST on November 15, 2011. Reason for not bidding: BY: Signature Name & Title (type or print) Company Name Date Page 8 of 37 Packet Pg. 44  F- 7] Drug -Free Workplace Form —ITB 12- 003 The undersigned vendor, on 2011, in accordance with Section 287. 087, Florida Statutes, certifies that [business] does: 1. Publish a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the workplace and specifying the actions that will be taken against employees for violations of such prohibition. 2. Inform employees about the dangers of drug abuse in the workplace, the business' s policy of maintaining a drug -free workplace, any available drug counseling, rehabilitation, employee assistance programs and the penalties that may be imposed upon employees for drug abuse violations. 3. Give each employee engaged in providing the commodities or contractual services that are under bid a copy of the statement specified in Paragraph 1. 4. In the statement specified in Paragraph 1, notify the employees that, as a condition of working on the commodities or contractual services that are under bid, the employee will abide by the terms of the statement and will notify the employer of any conviction of or plea of guilty or nolo contendere to, any violation of Chapter 893 or of any controlled substance law of the United States or any state, for a violation occurring in the workplace no later than five ( 5) days after such conviction. 5. Impose a sanction on, or require the satisfactory participation in a drug assistance or rehabilitation program if such is available in the employee' s community, by any employee who is so convicted. 6. Make a good faith effort to continue to maintain a drug -free workplace through implementation of Paragraphs I through 5. Check one: As the person authorized to sign this statement, I certify that this firm complies fully with above requirements. As the person authorized to sign this statement, this firm does not comply fully with the above requirements. NAME OF BUSINESS: BY: SIGNATURE NAME & TITLE, TYPED OR PRINTED: Paee 9 of 37 Packel Pg. 45 PUBLIC ENTITY CRIME FORM —ITB 12 -003 SWORN STATEMENT UNDER SECTION 287. 133 ( 3) ( A) FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED TO ADMINISTER OATHS. This sworn statement is submitted with Proposal, Proposal or Contract # This swom statement is submitted by whose business address is and ( if applicable) Federal Employer Identification Number ( FEIN) is ( If the entity has no FEIN, include the Social Security Number of the individual signing this sworn statement). My time is and my relationship to the entity named 1 understand that a " public entity crime" as defined in Pamgraph 287. 133( a)( g), Florida Statutes, means a violation of any state or federal law by a person with respect to and directly related to the transaction of business with any public entity or with an agency or political subdivision of any other state or with the United States, including, but not limited to, any proposal or contract for goods or services to be provided to any public entity or any agency or political subdivision of any other state or of the United States and involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation. I understand that " convicted" or " conviction" as defined in paragraph 287. 133( a)( b), Florida Statutes, means finding of guilt or a conviction of a public entity crime with or without an adjudication of guilt, in any federal or state trial court of records relating to charges brought by indictment or information after July 1, 1989, as a result of a jury verdict, non jury trial, or entry of a plea of guilty or note comendere. I understand that an " affiliate" as defined in Paragraph 287. 133( 1)( a), Florida Statutes, means A predecessor or successor of a person convicted of a public entity crime ( or) An entity under the control of any natural person who is active in the management of the entity and who has been convicted of a public entity crime. The term " affiliate" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in the management of an affiliate. The ownership by one of shares constituting a controlling income among persons when not for fair interest in another person, or a pooling of equipment or income among persons when not for fair market value under a length agreement, shall be a prima facie case that one person controls another person. A person who was knowingly convicted of a public entity crime, in Florida during the preceding 36 months shall be considered an affiliate. Page 10 of 37 Packet Pg. 46  0 I understand that a " person" as defrad in Paragraph 287. 133( 1)( e), Florida Statutes, means any natural person or entity organized under the laws of the state or of the United States with the legal power to enter into a binding contract for provision of goods or services let by a public entity, or which otherwise transacts or applies to transact business with a public entity. The term ' person" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active n management of an entity. Based on information and belief, the statement which I have marked below is true in relation to the Y u entity submitting this sworn statement. ( Please indicate which statement applies.) v Neither the entity submitting this sworn statement, nor any officers, directors, executives, v partners, shareholders, employees, members, or agents who are active in management of the entity, rc nor affiliate of the entity have been charged with and convicted of a public entity crime subsequent to av July 1, 1989. J0 The entity submitting this sworn statement, or one or more of the officers, directors, executives, partners, shareholders, employees, members, or agents who are active in management of the entity or an affiliate of the entity has been charged with and convicted of a public entity crime LC0LM 4 subsequent to July I, 1989. ( Please attach a copy of the final order.) in The person or affiliate was placed on the convicted vendor list. There has been a subsequent proceeding before a hearing officer of the State of Florida, Division of Administrative Hearings. The 0 i final order entered by the hearing officer determined that it was in public interest to remove the person or affiliate from the convicted vendor list. ( please attach a copy of the final order) The person or affiliate has not been placed on the convicted vendor list. ( Please describe any cuE U action taken by, or pending with, the Department of General Services.) mo°9 Signature) vNJO STATE OF: COUNTY OF: PERSONALLY APPEARED BEFORE ME, the undersigned authority, who, after first being NOC4L!_ m sworn by me, affixed his/ her signature at the space provided above on this day cu 2011, and is personally known to me, or has rE as identification. Notary Public My Commission expires Page II of 37 Packet Pg. 47