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

mN Facsimile Facsimile: Name: Name: Contact: Contact: Address: Address: Telephone: Telephone: Facsimile Facsimile: m0 N mr u0 am c LEE0M Page 7 of 27 Packet Pg. 98  F83. rn; u -uoa NO BID" RESPONSE TO INVITATION TO BID 0OO a IF YOU ARE NOT SUBMITTING A BID, PLEASE PROVIDE THE INFORMATION BELOW AND RETURN THIS FORM BEFORE THE SCHEDULED BID OPENING B DATE TO: rn c Purchasing Agent City of Fort Walton Beach v 105 Miracle Strip Pkwy, SW z Fort Walton Beach, F132548 Or by fax to ( 850) 833 -9643 FAILURE TO RESPOND TO THREE (3) CONSECUTIVE BIDS MAY RESULT IN r YOUR COMPANY BEING DELETED FROM THE CITY' S BIDDER'S LIST. m a We have received your invitation to bid for COMMERCIAL OVERHEAD STEEL a ROLLING DOORS, ITB No. 12 -008, Opening at 2: 30 PM CST, on December 13, 2011. r Reason for not bidding: a0OO N00 C W O R BY: L v Signature 0 Name & Title (type or print) ua Company Name 04N Date mt0-u 4fn CzaULNE Page 8 of 27 Packet Pg. 99  F83. i ac uel 0" bcnd'+ mN Drug -Free Workplace Form —ITB 12 -008 The undersigned vendor, on , 2011, 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 I, 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 cuntendere 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 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 drug -free workplace through implementation of Paragraphs 1 through 5. Check one: E As the person authorized to sign this statement, I certify that this firm complies 0 fully with above requirements. As the person authorized to sign this statement, this firm does not comply fully N with the above requirements. m V NAME OF BUSINESS: o nC0 BY: SIGNATURE E NAME & TITLE, TYPED OR PRINTED: zZ. Page 9 of 27 Packet Pg. 100  F830 PUBLIC ENTITY CRIME FORM (3 pages) - ITB # 12 -008 N SWORN STATEMENT UNDER SECTION 287. 133 ( 3)( A) 0 FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES av THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED TO ADMINISTER OATHS. 0of 1. This sworn statement is submitted with Bid, Proposal or Contract # rmv 0 2. This sworn statement is submitted whose business address is: aDo and ( if applicable) Federal Employer Identification Number m FEIN) is ( If the entity has no FEIN, include the Social Security Number of E the individual signing this sworn statement: 3 and my relationship to a 3. My name is the entity named above is mN 4. I understand that a " public entity crime" as defined in Paragraph 287. 133( a)( g). P Florida Statutes, means a violation of any state or federal law by a person with respect to 0 and directly related to the transaction of business with any public entity or with an agency or political subdivision of any other state or with the United States, including, but not N limited to, any bid or contract for goods or services to be provided to any public entity or c any agency or political subdivision of any other state or of the United States and involving o antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation. t 5. I understand that ' convicted" or " conviction" as defined in paragraph a 287. 133( a)( b), Florida Statutes, means finding of guilt or a conviction of a public entity crime with or without an adjudication of guilt, in any federal or state trial court of records relating to charges brought by indictment or information after July 1, 1989, as a result of a E jury verdict, non -jury trial, or entry of a plea of guilty or nolo contendere.