Fort Walton Beach Council agenda — 03-12-13--regular — reading text

aUA SWORN STATEMENT UNDER SECTION 287. 133 ( 3) ( A) FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES THIS FORM MUST BE SIGNED IN' rHE PRESENCE OF A NOTARY PUBLIC OR 01 FIER OFFICER AUTHORIZED TO ADMINISTER OATHS. this sworn statement is submitted with Proposal, Proposal or Contract 9 TH1302010 whose business address This sworn statement is submitted by GSC Systems, Inc. is 15 Industrial Street NW, Fort Walton Beach, F 332548 - and ( if applicable) Federal Employer Identification Number ( FEIN) is 59- 2914136 ( If the entity has no IT Include the Social Security Number of the individual signing this sworn statement). My name is Caralee M. Gibson and my relationship to the entity named above is President I understand that a " public entity crime" as defined in Paragraph 287. 133( a)( g), Florida Statutes, means a violation of any state or federal law by a person with respect to and directly related to the n' ansacuon of business with any public entity or with an agency or political subdivision of any other state of with the United Stales, including, bill not limited to, any proposal or contract for goads or services to be provided loony public entity of any agency or political subdivision of any other state ur of the United Slates and involving antitrust, fraud, theft, briber', collusion, racketeering, conspiracy, or material misrepresentation. I understand that "convicted" a "conviction" as def ned in paragraph 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 It court of records relating to charges brought by indictment or information after July 1, 19891 as a resuIt of a illry verdict, non -jury trial, or entry ofa ple10 1, guilty or nolo conlenderc. I understand that an " afNliale" as dctincd in Paragraph 287. 133( I)( a), Florida Statutes, means: A predecessor or successor o( a person convicted ofa public entity crime (or) An entity under the control of any natural person who is active in the management of the entity and who has been convicted of a public entity crime. ' file tell" " affiliate" includes those officers, directors, eFecul fives, partners, shareholders, employees-,members, and agents who are active in the management of all alfliate. 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 vahle nudes length agreement, shall be a prima facie case that one person controls another person. A person who was knowingly convicted of a public entity erime, in Florida during the preceding 36 months shall be considered an affiliate. 9 ur 28  6ulpue-I 040-£ 6 d=18 Pvemtl : OZZZ) swaISAS loquoo T swalsRS Rlunoss oS9 - Olo-El dJH . IuawgoeAtl a dm RFP # 13 - 010 P V L i" 1 S \'s n n a vY I understand that a " person' as defined in Paragraph 287. 133( l)( e), Florida Statutes, means any a 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' includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active it management of an entity. Based on information and belief, the statement which I have marked below is true in relation to the enti(yy submitting this sworn statement. ( Please indicate which statement applies.) Neither the entity submitting this sworn statement, nor any officers, directors, executives, partners, shareholders, employees, members, or agents who are active in management of the entity, noraffiliate of the entity have been charged with and convicted of public entity crime subsequent to July I, 1989. File entity submitting this sworn statement, or one or more of the officers, directors, executives, partners, shareholders, employees, members, or agents who are active in management of the entity or an affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July I, 1989. ( Please attach a copy of the Final order.) file person m affiliate was placed on the convicted vendor list. Thcrehasbeenasubsequent proceeding before a hearing officer ofthe State of Florida, Division of Administrat ive Hearings. The final order entered by the hearing officer determined that it was in public interest to mntovc the person or affiliate from the convicted vendor list. ( Please attach a copy of the final order) the person or affiliate has not been placed on dreconvictcd vendor list. ( Please describe any action taken by, or pending with, the Department of General Services,) Signature) 5 February 2013 Date) S "FAT OF: Florida COUNTY OF: Okaloosa PERSONALLY APPEARED 138FORE ME, the undersigned authoriq, whq after fint being sworn by me, affixed his /her signature at the space provided _above on this 5th clay of February 2013, and _ is personally known to me; or has provided as identification. Tasha Weeks, Notaty Public My Commission expires Fm Fx SWerber602 5 C,= yenn»rmrr v. rory m of 2a  E RPP # 13A10 Fort Walton Unding Sound System PROPOSER' S CERTIFICATION —RFP 13 -010 I have carefully examined the Request for Proposal; Instructions to Proposers, General and Special Conditions, Vendor's Notes, Scope of Work, proposed agreement and any other documents accompanying or made a part of this Proposal. I hereby propose to famish the goods or services specified in the Request for Proposal. I agree that my proposal will remain firm for a period of up to nine 90 days in order to allow the City m adequate time to evaluate the proposals. NT I certify that all information contained in this proposal is truthful to the best of my knowledge and c belief. I further certify that I am duly authorized to submit this proposal on behalf of the vendor /contractor as its act and deed and that the vendor /contractor is ready, willing and able to perform if awarded the proposal. I further certify, under oath, that this proposal is made without prior understanding, agreement, Naomc J connection, discussion, or collusion with any other person, firm or corporation submitting a proposal 0 for the same product or service; no officer, employee or agent of the City of Fort Walton Beach or of ari any other proposer interested in said proposal; and that the undersigned executed this Proposers a Certification with full knowledge and understanding of the matters therein contained and was duly authorized to do so. Dial Communications NAME OF BUSINESS 0an3 BY SIONATURE( % OPd(% N'AL- blueorbiackivk) Nn Nelson I. Sweeney / Vice -President & General Mgr NAME & TITLE ( type or print) Nc0 U dialcommunications @dialint. com EMAIL ADDRESS ( type or print) P. O. Box 6649 MAILING ADDRESS Tallahassee CITY, STATE, ZIP CODE FL 32314 - 6649 OUE0A 0 0 850) 877 - 3282 ( 850 1 877 - 0702 TELEPHONENUMBER FAX NUMBER LL 2013, Acknowledged & subscribed before me on the day of