Okaloosa County BOCC — September 3, 2013 — reading text

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 submittal. 12 Packet Pg. 90  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: _____________________________________ BY (PRINTED): _____________________________________ BY (SIGNATURE): _____________________________________ TITLE: _____________________________________ ADDRESS: _____________________________________ _____________________________________ PHONE NO. _____________________________________ E-MAIL _____________________________________ DATE ____ 13 Packet Pg. 91  DRUG-FREE WORKPLACE CERTIFICATION THE BELOW SIGNED PROPOSER CERTIFIES that it has implemented a drug-free workplace program. In 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 1, notify the employees that, as a condition of working on the commodities or contractual services that are under quote, 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 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, 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: _______________________ SIGNATURE: ____________________ COMPANY: _______________________ NAME: _________________________ (Typed or Printed) ADDRESS: _______________________ TITLE: _________________________ _______________________ E-MAIL: ________________________ _______________________ PHONE NO.: _______________________ 14 Packet Pg. 92  INDEMNIFICATION AND HOLD HARMLESS To the fullest extent permitted by law, CONTRACTOR shall indemnify and hold harmless COUNTY, its officers and employees from liabilities, damages, losses, and costs including but not limited to reasonable attorney fees, to the extent caused by the negligence, recklessness, or intentional wrongful conduct of the CONTRACTOR and other persons employed or utilized by the CONTRACTOR in the performance of this Agreement. ____________________________ __________________________ Proposer’s Company Name Authorized Signature – Manual ____________________________ __________________________ Physical Address Authorized Signature – Typed ____________________________ __________________________ Mailing Address Title ____________________________ __________________________ Phone Number FAX Number ____________________________ __________________________ Cellular Number After-Hours Number(s) ____________________________ DATE (REVISED: JANUARY 12, 2001) 15 Packet Pg. 93  FEDERAL E-VERIFY COMPLIANCE CERTIFICATION In accordance with Okaloosa County Policy and Executive Order Number 11-116 from the office of the Governor of the State of Florida, Proposer hereby certifies that the U.S. Department of Homeland Security’s E-Verify system will be used to verify the employment eligibility of all new employees hired by the contractor during the contract term, and shall expressly require any subcontractors performing work or providing services pursuant to the contract to likewise utilize the U.S. Department of Homeland Security’s E-Verify system to verify the employment eligibility of all new employees hired by the subcontractor during the contract term; and shall provide documentation of such verification to the COUNTY upon request. ========================================================== As the person authorized to sign this statement, I certify that this company complies/will comply fully with the above requirements. DATE: _______________________ SIGNATURE: ____________________ COMPANY: _______________________ NAME: _________________________ (Typed or Printed) ADDRESS: _______________________ TITLE: _________________________ _______________________ E-MAIL: ________________________ PHONE NO.: ___________________________ 16 Packet Pg. 94  NOTICE OF AWARD TO: PROJECT DESCRIPTION: The OWNER has considered the PROPOSAL submitted by you for the above-described WORK in response to its Advertisement for Qualifications dated __________________ and Information for Proposers. You are hereby notified that your PROPOSAL has been accepted for services at the rates attached hereto. You are required by the Instructions to Proposers to execute the Agreement and furnish the required CONTRACTOR’S Certificates of Insurance within fifteen (15) calendar days from the date of this notice to you. If you fail to execute said Agreement and to furnish said documents within fifteen (15) calendar days from the date of this notice, said OWNER will be entitled to consider all your rights arising out of the OWNER’s acceptance of your PROPOSAL as abandoned and as a forfeiture of your PROPOSAL. The OWNER will be entitled to such other rights as may be granted by law. You are required to return an acknowledged copy of this NOTICE OF AWARD to the OWNER: Okaloosa County Purchasing, 602-C North Pearl St., Crestview, FL 32536. If you have any questions, please call Jack Allen at 850-689-5960. Dated this ____ day of ____________, 2013. OWNER – OKALOOSA COUNTY BOARD OF COUNTY COMMISSIONERS BY: _________________________ TITLE Purchasing Director Richard L Brannon ACCEPTANCE OF NOTICE Receipt of the above NOTICE OF AWARD is hereby acknowledged. BY: ___________________________________________________ This the ________ day of ___________________, 2013. BY: ___________________________________________________ Title: __________________________________________________ 17 Packet Pg. 95  NOTICE TO PROCEED DATE: ________________ TO: PROJECT: ________________________________________________________ You are hereby notified to commence WORK in accordance with the Agreement dated _____________________, 2013, on or before _____________________, and you are to complete the WORK within __________________________________. The date of completion of all WORK is therefore _____________________________. You are required to return an acknowledged copy of this NOTICE TO PROCEED to the OWNER: Okaloosa County Purchasing, 602-C North Pearl St, Crestview, FL 32536. OKALOOSA COUNTY BOARD OF COUNTY COMMISSIONERS OWNER BY:_____________________________ Richard L. Brannon TITLE: Purchasing Director ACCEPTANCE OF NOTICE Receipt of the above NOTICE TO PROCEED is hereby acknowledged. ____________________________________ Company Name This the ________ day of _________________, 2013 ____________________________________ Signature By: _________________________________ Type or Print Name Title: ________________________________ 18 Packet Pg. 96  CONTRACT This agreement, executed in Crestview, Florida this _____ day of ___________________________ 2013 between the County of Okaloosa, Florida, the Owner, hereinafter called the Party of the First Part, and ______________________________ or its successors, executors, administrators and assigns, hereinafter called the Party of the Second Part. WITNESSETH: That for and in consideration of payments, hereinafter mentioned, to be made by the Party of the First Part, the Party of the Second Part agrees to furnish all equipment, machinery, tools and labor required to be furnished and