Fort Walton Beach Council agenda — 04-24-12 regular — reading text

order to allow the City adequate time to evaluate the bids. I certify that all information contained in this bid is truthful to the best of my knowledge and belief. I further certify that I am duly authorized to submit this bid on behalf of the vendor/contractor as its act and deed and that the vendor/contractor is ready, willing and able to perform if awarded the bid. I further certify that this bid is made without prior understanding, agreement, connection, discussion, or collusion with any other person, firm or corporation submitting a bid for the same product or service; no officer, employee or agent of the City of Port Walton Beach or of any other bidder interested in said bid; and that the undersigned executed this bidder' s Certification with full knowledge and understanding of the matters therein contained and was duly authorized to do so. NAME OF BUSINESS BY: Signature NAME & TITLE (type or print) MAILING ADDRESS CITY, STATE, ZIP CODE 1 TELEPHONE NUMBER 1 FAX NUMBER DATE Packet Pg. 32  8. 2. b n r, ADDENDUM PAGE FEB 12 -015 The undersigned acknowledges receipt of the following addenda to the Documents ( Give number and date of each): Addendum No. Addendum No. Addendum No. Addendum No. 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. a;Nn NAME OF BUSINESS BY Signature NAME & TITLE ( type or print) MAILING ADDRESS CITY, STATE, ZIP CODE 1 TELEPHONE NUMBER 1 FAX NUMBER DATE Packet Pg. 33  8. 2. b iM II i, e. t 1, I" J REFERENCES —ITB 12 -015 Bidder shall submit as a part 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. 34  8. 2. b tea, = dxr ar: d n, e 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: 0 u Purchasing Agent City of Fort Walton Beach c 105 Miracle Strip Pkwy, SW U0 Fort Walton Beach, F132548 m Or by fax to ( 850) 833 -960.3 a a FAILURE TO RESPOND TO THREE (3) CONSECUTIVE BIDS MAY RESULT IN YOUR m COMPANY BEING DELETED FROM THE CITY' S BIDDER' S LIST. c We have received your invitation to bid for SIDEWALK CONSTRUCTION ANNUAL BID, ITB No. c 12 -015, Opening at 2: 30 PM CST, on MARCH 8, 2012. Reason for not bidding: mr PNn c0E O0O BY: m Si fmawre ue0 Name & Title ( type or print) Company Name Y5NcU0 u Date PackM Pg. 35  8. 2. b IM r, Drug -Free Workplace Form —ITB 12- 015 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 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 eomendere 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 DO 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 drag -free workplace through implementation of Paragraphs 1 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: IF-Packet Pg. 36  8. 2. b PUBLIC ENTITY CRIME FORM INVITATION TO BID —ITB # 12 -015 SIDEWALK CONSTRUCTION ANNUAL BID SWORN STATEMENT UNDER SECTION 287. 133 ( 3)( A) FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES Nu2O THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER U0 OFFICER AUTHORIZED TO ADMINISTER OATHS. n 3a This sworn statement is submitted with Bid, Proposal or Contract N R 2. This sworn statement is c business address is: Qf the and ( if applicable) Federal entity has no FEIN, include the Social Employer NOH_ Identification Number (FEIN) is Number of the individual signing this sworn statement: inr Security mNr and my relationship to the entity 3. My name is C named above is E