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

FAX NUMBER 10- V3 -\-,) DATE Page 6 of 30  aseal Neo lIoE) 6Z0- Zt ddil : ££OZ) e4eme2 - lesodOJd - 6Z0- ZC dd21 : 11Jam43elttl an m a atLr CA T' RFP t+i2 -029 DRUG -FREE WORKPLACE FORM RFP 12- 029 sry a The undersigned vendor, on 10- 1 , 2412, in accordance with Section 287. 087, Florida Statutes, certifies that [ company] (, does: 6 c.. C.,,. r — I. 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 wi II be taken against employees for violations ofsuch 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 temts of the statement and will notify the employer of any conviction of or plea ofguilty or nolo contendere to, any violation of Chapter 893 or ofany controlled substance law Abe 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 1 through 5. Check one: As the person authorized to sign this statement, 1 certify that this firm complies fully with above requirements. 4s the person authorized to sign this statement, this firm does not comply lolly with the above requirements. NAME OF BUSINESS: BY: , m r SIG J N! ELE. TYPED OR PRINTED Page 8 of 30  asea- I Veo 1100 6ZO- U ddN : E£ OZ) egeweA - lesodoJd - 6ZO- ZL ddN m < GOLF IS uawgaRePP 1 2-029 p a PUBLIC ENTITY CRIME FORM —RFP 12- 029 Y 0 a SWORN STATEMEW UNDER SECTION 287.133 ( 3) ( A) FLORIDA STATUTES, ON PUBLIC ENTITYCRIIvIES 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 iurwhose business address This sworn statement is submitted byjlmp: , kc- is , and ( if applicable) Federal Employer Identification umber (FEIN) is a-J. a. 2.-' 1'- laC(If the entity has no FEIN, include the Social Security Number of the individual signing this sworn statement). My name is e i e s and my relationship to the entity named above is Yu ti S I understand that a " public entity crime" as defined in Paragraph 287.133( a)( g), Florida Statutes, means a violation ofany state or federal law by a person with respect to and directly related to the transaction o£ 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 ofa jury verdict, nonjury trial, or entry ofa plea of guilty or nolo contendere. I understand that an " affiliate" as defined in Paragraph 287. 133( I)( a), Florida Statutes, means: A predecessor or successor of 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 far interest in another person, or a pooling ofequipment 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 9 of 30  ase0-1 YeD; lorJ 6ZO -Zt d.AN a CCOZ) egewBk - lesodoad - 6Z0- Zl ddb uluawgoel V N 0 C) FCARIs RPP # 12. 229 I understand that a " person" as defined in Paragraph 287. 133( I)( e), Florida Statutes, means any 6 Y u a 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 entity submitting this swum statement. ( Please indicate which statement applies.) Ncither the entity submitting this sworn statement, nor any officers, directors. executives, partners, shareholders, employees, members, or agents who are active in management of the entity, nor affiliate of the entity have been charged with and convicted ofa public entity crime subsequent to July 1, 1989. The entity submitting this sworn statement or one or more of the officers, directors. executives. partners, shareholders, employees, members, or agents whom active in management of the entity or an affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. ( Please attach a copy ofthe final order.) The person or affiliate was placed on the convicted vendor list. There has been a subsequent proceeding before a hearing officer ofthe State of Florida, Division of Administrative Hearings. The 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 action taken by, or pending with, the Department of Ge eral Services.) Sig r Date) STATE OF': L-I- QD C AC- — OF: — f f PERSONALLY APPEARED BEFORE MP„ the undersigned authority, who, after fi}} g sworn by me. affixed / his/her signature at the space provided above on this J13LJ by 1., 1122, and is personally known to me, or has ofL("( fl" y(' DS{ providedl # O C i asidentification_ oSNIB i f Notary Public 0 My Commission expires VBLf0 7 'r t 8 z n t' Il4COt1NYS: anO Page 10 of 3a