Okaloosa County BOCC — December 18, 2012 — Request for Bids — reading text

during the contract term; and shall provide documentation of such verification to the OWNER 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.: ___________________________ Last Revised – 01/09/2013 Page 19  INDEMNIFICATION AND HOLD HARMLESS To the fullest extent permitted by law, CONTRACTOR shall indemnify and hold harmless OKALOOSA 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. ____________________________ __________________________ Bidder’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 (REVISED: JANUARY 12, 2001) Last Revised – 01/09/2013 Page 20  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 _____________________________________ Last Revised – 01/09/2013 Page 21  DRUG-FREE WORKPLACE CERTIFICATION THE BELOW SIGNED BIDDER 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.: _______________________ Last Revised – 01/09/2013 Page 22  RECYCLED CONTENT FORM RECYCLED CONTENT INFORMATION 1. Is the material in the above: Virgin_______ or Recycled__________ (Check the applicable blank). If recycled, what percentage ______________%. Product Description: ________________________________________________ ________________________________________________________________ ________________________________________________________________ 2. Is your product packaged and/or shipped in material containing recycled content? Yes__________ No___________ Specify: _________________________________________________________ ________________________________________________________________ ________________________________________________________________ 3. Is your product recyclable after it has reached its intended end use? Yes__________ No___________ Specify: _________________________________________________________ ________________________________________________________________ ________________________________________________________________ The above is not applicable if there is only a personal service involved with no product involvement. Name of Bidder: ________________________________________________________ E-Mail: Last Revised – 01/09/2013 Page 23  LOCAL PREFERENCE DATA SHEET Refer to Special Bid Condition Does the state, county, municipality or political subdivision in which your firm is located offer a preference to their local bidders? (If your firm is located in Okaloosa County, you will check “NO.”) If “YES,” list below the extent of such preference. YES____________________ NO_______________________ ________________________ __________________________________ ________________________ __________________________________ ________________________ __________________________________ ________________________ __________________________________ _____________________________ _______________________________ Bidder’s Company Name Authorized Signature – Manual ______________________________ _______________________________ E-Mail Authorized Signature – Typed Last Revised – 01/09/2013 Page 24  LIST OF SUBCONTRACTORS The BIDDER expressly agrees that: 1. If awarded the contract as a result of the proposal, the subcontractors used in the prosecution of the work will be those listed below. 2. The following list includes all subcontractors who will perform work on this project. 3. The subcontractors listed below are financially responsible and are qualified to do the work required. 4. Use of any of the subcontractors is subject to the approval of the County and Engineer. CATEGORY NAME OF SUBCONTRACTOR ADDRESS ________________________________ ________________________________ CONTRACTOR'S NAME AUTHORIZED SIGNATURE ________________________________ TITLE Last Revised – 01/09/2013 Page 25  PAYMENT BOND KNOW ALL PERSONS BY THESE PRESENTS: that (Name of Contractor) (Address of Contractor) a , hereinafter called Principal and (Corporation, Partnership or Individual) (Name of Surety) (Address of Surety) hereinafter called Surety, are held and firmly bound unto (Name of Owner) (Address of Owner) hereinafter called OWNER, and unto all persons, firms, and corporations who or which may furnish labor, or who furnish materials to perform as described under the contract and to their successors and assigns in the total aggregate penal sum of ____________ ______________________________ Dollars ($______________________________) in lawful money of the United States, for the payment of which sum well and truly to be made, we bind ourselves, our heirs, executors, administrators, successors, and assigns, jointly and severally, firmly by these presents. THE CONDITION OF THIS OBLIGATION is such that whereas, the PRINCIPAL entered into a certain contract with the OWNER, dated the __________ day of _______________, 20 _____, a copy of which is hereto attached and made a part hereof for _____________________________________________________________ __________________________________________________________________. NOW, THEREFORE, if the PRINCIPAL shall properly make payment to all persons, firms, and corporations furnishing materials for or performing labor in the prosecution of the WORK provided for in such contract and any authorized extensions or modification thereof, including all amounts due for materials, lubricants, oil, gasoline, coal and coke, repairs on machinery, equipment and tools, consumed or used in connection