Fort Walton Beach Council agenda — 04-26-11 regular — reading text

Fax: o MN r C U- U!V d Q Y C> 3L H Ld JR r C G t RV Page 90 of 93  Drug -Free Workplace Form The undersigned vendor, on , 2011, in accordance with section 287. 087, Florida Statutes, certifies that [ business] 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 drug -free workplace, any available drug counseling, a rehabilitation, employee assistance programs and the penalties that may be imposed upon employees for drug abuse violations. Y V 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. Z 4. In the statement specified in Paragraph 1, notify the employees that, as a condition of M J 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, M r0 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 a workplace no later than five ( 5) days after such conviction. U_ 5. E. E. 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 a employee who is so convicted. 00M 6. Make a good faith effort to continue to maintain a drug -free workplace through N r implementation of Paragraphs 1 through 5. LL Check one: a As the person authorized to sign this statement, I certify that this firm complies fully with above requirements. v L As the person authorized to sign this statement, this firm does not comply fully as with the above requirements. NAME OF BUSINESS: d E r BY: SIGNATURE NAME & TITLE, TYPED OR PRINTED: Page 91 of 93  PUBLIC ENTITY CRIME FORM SWORN STATEMENT UNDER SECTION 287. 133 ( 3) ( A) FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED TO ADMINISTER OATHS. This sworn statement is submitted with Bid, Proposal or Contract #, 2. This sworn statement is submitted by whose business address is and if applicable) Federal Employer Identification Number ( FEIN) is ( If the 49 U entity has no FEIN, include the Social Security Number of the individual signing this sworn statement). d a 3. My name is and my relationship to the entity named above is M 0 4. T 1 understand that a " public entity crime" as defined in Paragraph 287. 133( a)( g). Florida a Statutes, means a violation of any state or federal law by a person with respect to and LL directly related to the transaction of business with any public entity or with an agency or L political subdivision of any other state or with the United States, including, but not 3 limited to, any bid or contract for goods or services to be provided to any public entity or a any agency or political subdivision of any other state or of the United States and 00M involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material N r misrepresentation. c 5. 1 understand that " convicted" or " conviction" as defined in paragraph 287. 133( a)( b), U_ U U) Florida Statutes, means finding of guilt or a conviction of a public entity crime with or d a without an adjudication of guilt, in any federal or state trial court of records relating to co Y charges brought by indictment or information after July 1, 1989, as a result of a jury V 3 verdict, non -jury trial, or entry of a plea of guilty or nolo contendere. d 6. 1 understand that an " affiliate" as defined in Paragraph 287. 133( 1)( a), Florida Statutes, means: Jo Cd a. A predecessor or successor of a person convicted of a public entity crime (or) L RU b. An entity under the control of any natural person who is active in the management of El the entity and who has been convicted of a public entity crime. The term " affiliate" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in the management of an affiliate. The ownership by one of shares constituting a controlling income among persons when not for fair interest in another person, or a pooling of equipment or income among persons when not for fair market value under a length agreement, shall be a prima facie case that one person controls another person. A person who was knowingly convicted of a public entity crime, in Florida during the preceding 36 months shall be considered an affiliate. Page 92 of 93  14.2. 6 7. 1 understand that a " person" as defined in Paragraph 287. 133( 1)( e), Florida Sta u es, means any natural person or entity organized under the laws of the state or of the United States with the legal power to enter into a binding contract for provision of goods or services let by a public entity, or which otherwise transacts or applies to transact business with a public entity. The term " person"