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

Signature 6Dh psrJ , iQeS _ NAME & TITLE (type or print) R4 N MoAr, RS-I MARLING ADDRESS ICS( Q CITY, STATE, ZIP CODE Pj r-T -- 1r, TELEPHONE NUMBER FAX NUMBER op, In Lq lao /3 DATE 6 028  wels6g punog 6u' Puel OtO-£ t d=IU Premtl : OZZZ) sjalseWolsnW - OtO-£ t dd21 auawgoeliv Na F rtW 1 Lmdiug S d5 RFP 013- 010 a DRUG -FREE WORKPLACE FORM RFP 13 -010 Y U 2013, in accordance with Section 287. 087, The undersigned vendor, on // y, 1-/- i , does: Florida Statutes, certifies that [company] I)I lci illac+ers 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. 1 Give each employee engaged in providing the commodities or contractual services that me under bid a copy of the statement specified in Paragraph 1. 4. In the statement specified in Paragraph 1, 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 terns 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 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: / As the person authorized to sign this statement, I certify that this firm complies fully with above requirements. As the person authorized to sign this statement, this firm does not comply fully with the above requirements. NAME OF US S: I t 1 V S f i. Y I lar5- 4--,r5 BY: SIGNATURE Lea NAME & TI , q nL Orson) TYPED O 1 PRINTED 9 of28  welsAS Punog BulPuel OfO'£ I d.18 Psemlf : OZZZ) syalseyyolsnyil - O1, 0-£ L dd2l : luawyciERV N rn Pun lb" Iwnl , S S J9 sc RPP_, I1loq w N a a I understand that a " person" as defined in Paragraph 287. 133( 1)( e), Florida Starnes, 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 n management of an entity. Based on influrcloon and belief, the statement which I have marked below is true in relation to the entity submtfing this sworn statement. { Please indicate Much statement applies.) Neither the entity submitting this sworn statement, nor any officers, directors, executives. pnrtners, shareholders, 0mployces, me3nbers. or agents who are active in manacemutt of the entity. nor aft iliate of the entity have been charged with and convicted of a public entity crime subsequent to July I, 1982 1110 entity submittung this sworn statement, or one or more of the officers, di eclors, exeentiveS. part ners, shareholders, employees, members, or agents who aze active in uanagement of the emir ur an affiliate of the entity has been charged with and convicted of a public entity crulie subsequent to July I, 1959. ( Please attach a copy of the final order.) The person or affiliate was placed on the convicted vendor list. There has beena subsequent proceeding before a hearing officer of tile Stateof Florida, Division ofAdmmisirauve Beanngs. The final order entered by the hearing oRlcer determined that it was in public interest to remoae the person or affiliate from the concreted vendor list. ( Please attach a copy of the final order) I' he person or aiidiate has not been placed an the convicted vendor list. ( Please descl be any action taken by, or pending with, the Department of^Geneial Services _I Stue) Q Date) SlATI OF Ai% (' 01 ! N um__ PERSONALLY .APPEARED BEFORE ME, the undersigned authority, who, after first being Wro by mc, aflixai his /hu signanre at tine space provided above on this 4"' day of f 2013, and is personally known to me, or has provided. __ r _. ungi.. _ as identification. 90HA 0 Notary P blic klv(' ommissionexpires 1- 1q - 3 Ai si, LINDSEY A. SCOTT Nonry POW - State of ftorlpa E`9's 5+'` ta,, V MyCommtaalon Comm. Eapina Sep 11, 2573 l D0925158 10" 1' 29  3 N m C:,/ z Attachment: RFP 13 -010 MusicMasters ( 2220 : Award RFP 13 -010 Landing Sound System) am  walsGg punog Bulpuel OLO-£ L d=18 PJumV a OZZZ) sjalsepynlsnpy - DLO -EL dAN auawy3ullV ev it 4 bpress Package SPM-- h rvom wAU H. n., nm w a t IF NeiAM V 4. 1 a'ew n 7 v 5 Packaging wmc SrnmSrnm YnurYnur ImnmalImnmal BillhgBillhg RdarexeRdarexe ClCl G Spociel NandlinO and Oelivery5ignafwe OVlians Donl[Donl[ 44 PIPI n6n6 ee