Okaloosa County BOCC — January 21, 2014 — Hatch Mott — reading text

COUNTY upon request. As the persan authorized to sign this statement, I certify that this company complies/will comply fully with the above requirements. DATE: October 25, 2013 seurmBet : COMPANY: Hatch Mott MacDonald Florida, LLC NAME: _ Charles G. naxte/. Zo Aporess; °111 North 12th Avenue TITLE: __ Executive Vice President Pensacola, FL 32504 E-MAIL: charles. baxley@hatcnmott.com PHONE NO.: 950-484-6011 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: Hatch Mott MacDonald Florida, LIC BY (PRINTED): Charles 6. Baxley, PET BY (SIGNATURE): Hake bs. A, TITLE: Executive Vice Presider ADDRESS: §111 North 12th Avenue Pensacola, FL 32504 PHONE NO. 850-484-6011 12 DRUG-FREE WORKPLACE CERTIFICATION THE BELOW SIGNED BIDDER CERTIFIES that it has implemented a drug-free workplace program. tn 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 i, notify the employees that, as a condition of working on the commodities or contractual services that are under quate, 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 contralled 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: Ceroher 25. 2013 SIGNATURE: Webi bal COMPANY: Hatch Mott MacDonald Florida, ELCNAME: Charles G. Baxley, PE Vai (Typed or Printed) ADDRESS: 5111 North 12th Avenue TITLE: Executive Vice President Pensacola, FL 32504 PHONE NO.: 350-484-6011 13