Fort Walton Beach Council agenda — 05-08-12 regular — reading text

m0 N CITY, STATE, ZIP m 1 C TELEPHONE NUMBER E 1 rum FAX NUMBER Q DATE p,, , - of °P. Packet Pg. 31  8. 2. b ADDENDUM PAGE —ITB 12 -018 The undersigned acknowledges receipt of the following addenda to the Documents ( Give number and date of each): Addendum No. Addendum No. Dated v m0 Datcd Addendum No. CO Dated LL Addendum No. r o FAILURE TO SUBMIT ACKNOWLEDGMENT OF ANY ADDENDUM THAT AFFECTS THE BID PRICES IS CONSIDERED A MAJOR IRREGULARITY AND WILL BE CAUSE FOR REJECTION OF THE BID. Nu3am mH NAME OF BUSINESS Signature NAME & TITLE ( type or print) MAILING ADDRESS CITY, STATE, ZIP CODE 1 TELEPHONE NUMBER 1 FAX NUMBER Pa ; b„ P' Paeket Pg. 32  8. 2. b REFERENCES ITB 12 -0I8 Bidder shall submit as a pan of the bid package, four ( 4) business references with name of the business, address, contact person, and telephone number. All references shall be for similar product that has been delivered within the last five (5) years. REGARDING PROPOSER I BIDDER: Name: Name: Contact: Contact: Address: Address: Telephone: Telephone: Facsimile Facsimile: Name: Name: Contact: Contact: Address: Address: Telephone: Telephone: Facsimile Facsimile: Packet Pg. 33  8. 2 .6 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 v 105 Miracle Strip Parkway SW c Fort Walton Beach, IT 32548 Or by fax to (850) 833 -9643 0 LL 8 FAILURE TO RESPOND TO THREE (3) CONSECUTIVE BIDS MAY RESULT IN YOUR COMPANY BEING DELETED FROM THE CITY' S BIDDER' S LIST. m We have received your invitation to bid for 50HP DIESEL TRACTOR WITH HYDRAULIC FRONT LOADER, ITB# 12 -018, Opening at 2: 30 PM, CST on April 17, 2012. Reason for not bidding: m oN mf mmr caE BY: u Signature c za a Name & Title ( type or print) i uf Company Name Date se3E I'. , I Packet Pg. 34  8. 2. b Drug -Free Workplace Form – ITB 12 -018 The undersigned vendor, on 2012, in accordance with Section 287. 087, does: Florida Statutes, certifies that [ business] 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 m specifying the actions that will be taken against employees for violations of such prohibition. aJc 2. Inform employees about the dangers of drug abuse in the workplace, the business' s policy of o maintaining a drug -free workplace, any available drug counseling, rehabilitation, employee a. assistance programs and the penalties that may be imposed upon employees for drug abuse E. violations. o V 3. Give each employee engaged in providing the commodities or contractual services that are F under bid a copy of the statement specified in Paragraph I. m3 4. In the statement specified in Paragraph 1, notify the employees that, as a condition ofworking m 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 eontendere to, any violation of Chapter 893 or of any controlled substance Law of the mL United States or any state, for a violation occurring in the workplace no later than five ( 5) days after such conviction. m 5. Impose a sanction on, or require the satisfactory participation in a drug assistance or c rehabilitation program if such is available in the employee's community, by any employee E who is so convicted. 0 6. Make a good faith effort to continue to maintain a drug -fret workplace through v implementation of Paragraphs I through 5. anro0 Check one: As the person authorized to sign this statement, I certify that this firm complies fully m L with above requirements. Ca As the person authorized to sign this statement, this firm does not comply fully with L the above requirements. a NAME OF BUSINESS: _ BY — SIGNATURE NAME & TITLE, TYPED OR P. rnt Packet Pg. 35  8. 2. 0 PUBLIC ENTITY CRIME FORM —ITB 12 -018 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 # Dv J0 This sworn statement is submitted by _ whose business address 0 is and ( if applicable) Federal Employer LL Identification Number ( FEIN) is _ ( If the entity has no FEIN, include the Social