Okaloosa County BOCC — September 16, 2014 — RFP EMS 63-14 — reading text

disqualification of my proposal/submittal.  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), of 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: _____________________________________ ADDRESS: _____________________________________ _____________________________________ PHONE NO. _____________________________________ E-MAIL _____________________________________  DRUG-FREE WORKPLACE CERTIFICATION THE BELOW SIGNED PROPOSER CERTIFIES that it has implemented a drug-free workplace program. In order to have a drug-free workplace program, a business shall: 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 and 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 quote a copy of the statement specified in subsection 1. 4. In the statement specified in subsection 1, notify the employees that, as a condition of working on the commodities or contractual services that are under quote, 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, drug abuse assistance or rehabilitation program if such is available in employee’s community, by any employee who is convicted. 6. Make a good faith effort to continue to maintain a drug-free workplace through implementation of this section. As the person authorized to sign this statement, I certify that this firm complies fully with the above requirements. DATE: _______________________ SIGNATURE: ____________________ COMPANY: _______________________ NAME: _________________________ (Typed or Printed) ADDRESS: _______________________ TITLE: _________________________ _______________________ E-MAIL: ________________________ _______________________ PHONE NO.: _______________________  INDEMNIFICATION AND HOLD HARMLESS To the fullest extent permitted by law, CONTRACTOR shall indemnify and hold harmless COUNTY, its officers and employees from liabilities, damages, losses, and costs including but not limited to reasonable attorney fees, to the extent caused by the negligence, recklessness, or intentional wrongful conduct of the CONTRACTOR and other persons employed or utilized by the CONTRACTOR in the performance of this Agreement. ____________________________ __________________________ Proposer’s Company Name Authorized Signature – Manual ____________________________ __________________________ Physical Address Authorized Signature – Typed ____________________________ __________________________ Mailing Address Title ____________________________ __________________________ Phone Number FAX Number ____________________________ __________________________ Cellular Number After-Hours Number(s) ____________________________ DATE  FEDERAL E-VERIFY COMPLIANCE CERTIFICATION In accordance with Okaloosa County Policy and Executive Order Number 11-116 from the office of the Governor of the State of Florida, Proposer hereby certifies that the U.S. Department of Homeland Security’s E-Verify system will be used to verify the employment eligibility of all new employees hired by the contractor during the contract term, and shall expressly require any subcontractors performing work or providing services pursuant to the contract to likewise utilize the U.S. Department of Homeland Security’s E-Verify system to verify the employment eligibility of all new employees hired by the subcontractor during the contract term; and shall provide documentation of such verification to the COUNTY upon request. ========================================================== As the person authorized to sign this statement, I certify that this company complies/will comply fully with the above requirements. DATE: _______________________ SIGNATURE: ____________________ COMPANY: _______________________ NAME: _________________________ (Typed or Printed) ADDRESS: _______________________ TITLE: _________________________ _______________________ E-MAIL: ________________________ PHONE NO.: ___________________________  CONTRACT This agreement, executed in Crestview, Florida this _____ day of ___________________________ 2014 between the County of Okaloosa, Florida, the Owner, hereinafter called the Party of the First Part, and _________________ or its successors, executors, administrators and assigns, hereinafter called the Party of the Second Part. WITNESSETH: That for and in consideration of payments, hereinafter mentioned, to be made by the Party of the First Part, the Party of the Second Part agrees to furnish all equipment, machinery, tools and labor; to furnish and deliver all materials required to be furnished and delivered in and about the improvement and to do and perform all work in providing collection agency services for EMS for costs set forth in the attached proposal in strict conformity with the provisions of this Contract, the Notice to Proposers, the Specifications and the Proposal approved by the Owner. The said Specifications, the Notice to Proposers, and the Proposal are hereby made a part of this agreement as fully and to the same effect as if the same had been set forth at length in the body of this agreement. As security for the full and faithful performance of this contract and all the incidents thereto, the Party of the Second Part will make and furnish a Performance Bond and Payment Bond with as Surety, which is accepted by Parties of the First Part and made a part of this contract. In consideration of the foregoing promises, the Party of the First Part agrees to pay to the Party of the Second Part such unit prices for the work actually done as are set out in the accompanying proposal in the manner provided in the said Specifications. This contract shall be in effect upon completion of signatures by both parties and shall run through ___________________. This contract may be renewed upon agreement by both parties for an additional ______________ periods. Attached prices shall be fixed until __________________. Attached prices may be adjusted annually during the renewal period per written agreement by both parties and based on the Producers Price Index published monthly by the U.S. Department of Labor, Bureau of Labor Statistics, for the price of goods. The only addition increase during the contract period would be due to the postage costs. The Contractor shall be prepared to begin work to be performed under the contract as he set forth in his proposal, but will not proceed until he receives official notice to begin. REPRESENTATIVES: The authorized representative of the County shall be: Dino Villani Okaloosa County Public Safety 90 College Blvd East Niceville, FL 32578 850-651-7150 E-Mail: dvillani@co.okaloosa.fl.us The authorized representative for __________________________shall be: _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ E-mail _________________________________ All notices required by this agreement shall be in writing to the representative listed above with a courtesy copy to the following: Joanne Kublik Contracts & Leases Okaloosa County Purchasing Department 602-C North Pearl Street Crestview, FL 32536 850-689-5960 / 850-689-5998 (FAX) E-Mail: jkublik@co.okaloosa.fl.us IN WITNESS WHEREOF, the Chairman of the Board of County Commissioners, by authority vested in him, has hereunto subscribed his name on behalf of the County of Okaloosa, Florida, the Owner, and the said has hereto fixed his signature, the day and year above written. WITNESS: Contractor BY TITLE STATE OF FLORIDA COUNTY OF OKALOOSA This contract is accepted this _____ day of _____________________ 2014 and is effective on the _____ day of _________________________ 2014. ATTEST: COUNTY OF OKALOOSA, FLORIDA BY Gary Stanford Charles K. Windes, Jr., Chairman Deputy Clerk of Court  EMS COLLECTION SERVICES RANKING SHEET BID # EMS COMPANY NAME Percentage Cost of