Okaloosa County BOCC — April 27, 2013 — reading text

DATE IS SPECIFIED). _________________________________________________________________________________________________________ THIS SPACE FOR RECORDER'S USE ONLY I attest to the correctness of the information above. _________________________________________________ Authorized Department Signature The foregoing instrument was acknowledged before me this _____ day of _________________, 20___, by ____________ ______________________, who is personally known to me or who has produced ___________________________ as identification and who did/did not take an oath. _________________________________________________ 43 Packet Pg. 842  8.6.c.c NOTARY PUBLIC _________________________________________________ MY COMMISSION EXPIRES Attachment: Compare version 5 with original.pdf (1517 : Revisions to the Purchasing Manual) 44 Packet Pg. 843  8.6.c.c TASK ORDER APPROVAL FORM CONTRACT #: TASK ORDER #: TASK ORDER AMOUNT: $__________________________ Attachment: Compare version 5 with original.pdf (1517 : Revisions to the Purchasing Manual) OFFERED BY CONSULTANT: FIRM’S NAME REPRESENTATIVE’S PRINTED NAME SIGNATURE TITLE DATE RECOMMENDED FOR APPROVAL APPROVED BY OKALOOSA COUNTY (Department Director) (Per Purchasing Manual) SIGNATURE SIGNATURE TITLE TITLE DATE DATE 45 Packet Pg. 844  8.6.c.c CONTRACT/LEASE RENEWAL FORM Date: Attachment: Compare version 5 with original.pdf (1517 : Revisions to the Purchasing Manual) Company Name Attn: Address City, State, Zip RE: Dear : The Okaloosa County agrees to renew the subject contract/lease, # for an additional term. The contract renewal period will be ____ to . The annual budgeted amount for this contract is $______________. If you are in agreement, please sign below and return this form along with a current Certificate of Insurance listing Okaloosa County as co-insured (if applicable). COUNTY REPRESENTATIVES AUTHORIZED COMPANY REPRESENTATIVE Dept. Director Contractor: ______ Signature: Approved By: Approved By: (as prescribed below on item 1) Title: Title: Date: Date: County Department Instructions: 1) Obtain signatures from Department Director, authorized Company Representative and then Purchasing Director <$25K and less, County Administrator <$50K and less or Board >$50K, as necessary. Make sure the company provides a current Certificate of Insurance. (If applicable). 46 Packet Pg. 845  8.6.c.c 2) Keep a copy of this form for your records. 3) Send original to Purchasing Services Coordinator. If you have any questions please contact the Purchasing Director at 850-689-5960, Fax: 850-689- 5998. Attachment: Compare version 5 with original.pdf (1517 : Revisions to the Purchasing Manual) 47 Packet Pg. 846  8.6.c.c OKALOOSA COUNTY BOARD OF COUNTY COMMISSIONERS COUNTY ISSUED WIRELESS COMMUNICATION DEVICE USAGE AGREEMENT CERTIFICATION COUNTY OFFICIAL/EMPLOYEE CERTIFICATION Attachment: Compare version 5 with original.pdf (1517 : Revisions to the Purchasing Manual) I hereby certify by my signature that I have been provided a copy of the County policy for Wireless Communication Device; that I have read and understand the requirements contained therein; and that I agree to comply with the requirements of the policy as now written or amended in the future. Printed Name of Authorized User: Signature of Authorized User: Date: _____________ Name of Department: Type of Equipment Requested: CIRCLE ALL THAT APPLY Smart Phone, PDA (Blackberry), Cellular, Push to Talk Radio (Link), Pager, Air Card APPROVED BY: Department Director’s Signature: Date: Requesting Department complete the following information & fax to: Purchasing Dept. @ 850-689-5970 Wireless Communication Device: Mfr Model Serial #: Wireless Telephone #: 48 Packet Pg. 847  8.6.c.c 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), or if any of its agencies is also an owner, corporate officer, agency, employee, etc., of their business. Attachment: Compare version 5 with original.pdf (1517 : Revisions to the Purchasing Manual) 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 _____________________________________ 49 Packet Pg. 848  8.6.c.c NO CONTACT CLAUSE The Board has established a solicitation silence policy (No Contact Clause) that prohibits oral and written communication regarding all formal solicitations for goods and services (formal bids, Request for Proposals, Requests for Qualifications) issued by the Board through the County Attachment: Compare version 5 with original.pdf (1517 : Revisions to the Purchasing Manual) Purchasing Department. The period commences when the procurement document is received and terminates when the Board approves an award. When the solicitation silence period is in effect, no oral or written communication is allowed regarding the solicitation between prospective bidders/proposers and members of the Board, the County Administrator or members of the Board Approved Review Committee. All questions or requests for information regarding the solicitation must be directed to the designated Purchasing Representative listed in the solicitation. Any information thought to affect the committee or staff recommendation submitted after bids are due, should be directed to the Purchasing Director or his appointed representative. It shall be the Purchasing Director’s decision whether to consider this information in the decision process. Any violation of this policy shall be grounds to disqualify the proposer from consideration during the selection process. All proposers must agree to comply with this policy by signing the following statement and including it with their submittal. I representing Signature Company Name hereby agree to abide by the County’s “No Contact Clause” and understand violation of this policy shall result in disqualification of my proposal/submittal. 50 Packet Pg. 849  8.6.c.c SELECTION COMMITTEE MEMBER INSTRUCTIONS You have been selected to serve on a Board-approved Review and Recommendation Committee for services for Okaloosa County. 1. You will be given a copy of all proposals received for this service. 2. You are required to read and review each proposal, make written notes as to the Attachment: Compare version 5 with original.pdf (1517 : Revisions to the Purchasing Manual) proposal meeting the following criteria: a. Did the response meet the requested format? b. Did the proposal include all required documentation? c. Does this firm seem capable of producing the services requested? 3. Fill out the provided ranking sheet for each firm. 4. At a duly noticed meeting, all Committee