Fort Walton Beach Council agenda — 01-24-12 regular — reading text

00N_ FAILURE TO SUBMIT ACKNOWLEDGMENT OF ANY ADDENDUM THAT AFFECTS m THE BID PRICES IS CONSIDERED A MAJOR IRREGULARITY AND WILL BE CAUSE FOR REJECTION OF THE BID. aR Q CHAMPION CONTRACTORS, INC. NAME OF BUSINESS B Sia J Q Signatue Howard Holley President NAME & TITLE (type or print) P. O. Box 155 MAH.ING ADDRESS Crestview, Florida 32536 CITY, STATE, ZIP CODE 850 423 - 0235 mt- TELEPHONE NUMBER a4 1 850) 423 - 0480 FAXNUMBER 13 December 2011 cvE DATE um a Page 6 of 27 Packet Pg. 68  8. 3. 6 rrD 412 MIS coum.n 6.110'. 0.•,n st' l Rou REFERENCES —1TB 11. 008 O0OO Bidder shall submit as a part of the bid package, four (4) business references with name of the a business, address, contact person, and telephone number. All references shall be for similar product that has been delivered within the last five (5) years. c_ REGARDINGPROPOSER / BIDDER: CHAMPION CONTRACTORS, INC. 0oFNa_ v w Housin Authority k Housing thorit O r1W. Adams Hickory ckory Ave F1 32536 Debbs ct ess: Ed LDr. k, A m00 m aR hone: 850) 682 - 2413 4) 7 E Facsimile: 850) mile 34) 4 Eglin Name: AFB, F1 e:Life Missionary Church Contact: Mr. Ken Stanley tact: Sanfes GWEF- Address:Bldg 374 ress: Dugg 285Duggan Crestview, F1 32536 E lin AFB, F1 Telephone: Telephone: 850) 621 - 4186 850) 882 - 9987 Facsimile: Facsimile m w00N CmaEs0 Page 7 of 27 Packet Pg. B9  8. 3. b rrufluams G,mmn <„d O, -. r id srMa aaumc1Nror, Drug -Free Workplace Form —rfB 12-008 The undersigned vendor, on 13 December 2011, in accordance with section 287.087, Florida Statutes, certifies that [busincss] rvAwmN CONTRACTORS Cur does: 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 a 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 note contandem to, any violation of Chapter 893 or of my controlled substance law of the United States or my slate, for a violation occurring in the workplace 5. no later than five (5) days after such conviction. Impose a sanction on, or require the satisfactory participation in a drug assistance or uamo c rehabilitation program if such is available in the employee's community, by my v employee who is so convicted. 0 6. Make a good faith effort in continue to maintain a drug -free workplace through implementation of Paragraphs I tbrough 5. aEm U J Check one: 1 As the person authorized to sign this statement. I certify that this firm complies N 0 My with above requirements. 0 As the person authorized to sign this statement, this firm does not comply fully ca with die above requirements. NAME OFF\ BUSINESS: CHAMPION CONTRACTORS, INC. imnF 4 N 13Y: C1 SIGNATURE NAME & TITLE, TYPED OR PRINTED: Howard Holley, President c0mrE Page 9 of 27 Packet Pg. 70  8. 3. b I'T11412 608 CmnnmrcW O, eft.. W and main M. 11 PUBLIC ENTITY CRIME FORM (3 pages) - ITB it 12-008 SWORN STATEMENT UNDER SECTION 287. 133 ( 3XA) NO 0 FLORIDA STATUTES ON PUBLIC ENTITY CRIMES THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC dNm OR OTHER OFFICER AUTHORIZED TO ADMINISTER OATHS. c_ m This mom statement is submitted with Bid, Pmposal or Contract # ITB12 - 008 0KaN N 2. This mom statementissubmittedChampion Contractors, Inc. O whose business address is: 505 N Ferdon Blvd Crestview. F1 32536 m0 and ( if applicable) Federal Employer Identification Number