HomeMy WebLinkAboutAffidavit4.4. MINORITY/WOMEN BUSINESS AFFAIRS REGISTRATION AFFIDAVIT
Please Check One Box Only [ ] Hispanic [ ] Female [ ] Black Not Applicable
If business is not 51% minority/female owned , affidavit does not apply. If not applicable, notariza ion is not required.
I (We), the undersigned agree to the following conditions:
I) that we have read Section 2.25 of the General Terms and meet the fifty-one percent (51%) ownership and
management requirement for minority/women registration status and will abide by all of the policies and
regulations governing the City of Miami Minority and Women Business Enterprise Procedures;
2) that if at any time information submitted by the undersigned applicant in his/her Bidder Application should
prove ..to..be..falce,. inaccurate, .or..misleading,..app]icant's name. will. be. struck..from... the ...City .of.Miami '.s ..
Master Bidder list with no further consideration given to this applicant;
3) that the City of Miami maintains the right, through award of bid/contract, to revoke the award, should it be
found that false, inaccurate or misleading information or a change in the original information have occurred;
4) to notify the City of Miami within thirty (30) days of any change in the firm's ownership, control,
management or status as an ongoing minority/women business concern as indicated on the Bidder
Application, and that the City of Miami, upon a finding to the contrary, may render a firm's registration
with the City nulland void and cease to include that firm in its registered list of minority and women -owned
businesses;
5) that the City of Miami has a right to diligently verify all information submitted by applicant in his/her
Bidder Application to monitor the status of the Minority/Women Business Enterprise, once registered;
6) that I e City of Miami may share a firm's registration information concerning its minority/women status and
its capability with other municipal or state agencies for the sole purpose of accessing the firm to their
proefirement opportunities, unless otherwise specified by the firm in writing.
I (We) certify under the penalties of perjury that the information contained in any and all application documents
submitted to the City of Miami is correct as per Ordinance No. 10062 as amended.
Firrn Name:
(If signing as a corporate officer, kindly affix corporate seal)
(Name, Title & Date) (Name, Title & Date)
This application must be signed by at least one general partner of a partnership or the proprietor of a sole
proprietorship or all partners of a joint venture.
COUNTY, SS
COUNTY OF DADE
That:
NOTARIZATION
Date:
personally appeared before me and
acknowledged the foregoing instrument as his/her act and deed.
That he/she has produced as identification.
NOTARY PUBLIC:
My Commission Expires:
FAILURE TO COMPLETE, SIGN, AND RETURN THIS FORM MAY DISQUALIFY THIS BID.
City of Miami Page 44
Bid No. 06-06-035
4.5. SAMPLE OF AFFIRMATIVE ACTION POLICY for EQUAL EMPLOYMENT
OPPORTUNITY
AFFIRMATIVE ACTION/
EQUAL EMPLOYMENT OPPORTUNITY - POLICY STATEMENT
It is the policy of (Company Name) to base its hiring and promotions on merit, qualifications and competency and
that its personnel practices will not be influenced by an applicant's or employee's race, color, place of birth, religion,
national origin, sex, age, marital status, veteran and handicapped status.
One of the management duties of all principals at (Company Name) is to ensure that the following personnel
practices are.being satisfied .... ........._....,.......__...................:..,..,....:................_...
I. Take every necessary affirmative action to attract and retain qualified employees, regardless of race, color,
place of birth, religion, national origin, sex, age, marital status, veteran and handicapped status.
2. Maintain equitable principles in the recruitment, hiring, training, compensation and promotion of employees.
3. Monitor and review personnel practices to guarantee that equal opportunities are being provided to all
employees, regardless of race, color, place of birth, religion, national origin, sex, age, maritalstatus, veteran
and handicapped status.
(Company Name) is committed to take affirmative action and aggressively pursue activities that will serve to enable
all employees and applicants opportunities available throughout this organization.
Clearly, the above act' ns cannot be accomplished as a secondary duty for any individual, despite the full support of
management. And so, monitor our efforts, (Company Name) has assigned one of its principals as the Affrnnative
Action Director to monitor all activities of this program.
Employees may contact (Name of assigned principal) at (telephone number) regarding this Affirmative Action
Policy.
DATE:
(SIGNATURE/TITLE):
FAILURE TO COMPLETE, SIGN, AND RETU.RN THIS FORM MAY DISOUALIFY THIS BID.
City of Miami Page 45
Bid No. 05-06.035
4.6. OFFICE LOCATION AFFIDAVIT
Please type or print clearly. This Affidavit must be completed in full, signed and notarized ONLY if your office is located within the
corporate limits of the City of Miami,
Legs[ Name of Finn:
Entity Type: (check ane box only) [] Partnership
[j Sole Proprietorship [j Corporation
Corporation Doc. No:
Date Established:
Occupational License No: Date of Issuance:
oV24g6:10Ei n,F �,.J•.u..:
PRESENT
Street Address:
City:
State:
How long at this location:
PREVIOUS
Street Address:
City:
fJbT J/fg
State How long at this location:
According to Ordinance No. 12271 (Section 18-85):
The City Commission may other to a responsible and responsive Iota] bidder, who maintains a Local Office, the opportunity of accepting a bid at
the low bid amount, if the original bid amount submitted by the local vendor is not more than ten percent f10°/9) in excess of the lowest other
responsible and responsive bidder,
The intention of this section is to benefit local bona fide bidders/proposers to promote economic development within the corporate limits
of the City of Miami.
I (we) certify, under penally of perjury, that the office location of our firm has not been established with the sole purpose of obtaining the
advantage granted bona fide local biddea€tfproposers by this section.
Authorize Signature
Print Name
(C01",,)ori" 1,x,' c. ,1.) Title
Authorize Signature
Print Name
Title
(Must be signed by the corporate secretary of a Corporation or one general partner of a partnership or the proprietor of a sole proprietorship or all
partners of a joint venture.)
STATE OF FLORIDA, COUNTY OF DADE
p Personally known to me; or
Subscribed and Sworn before me that this is. a true statement this day of 199 . [] Produced identification:
Notary Public, State of Florida My Commission expires
Printed name of Notary Public
Please submit with your bid copies of Occupational License, professional and/or trade License to verify local status. The City of Miami
also reserves the right to request a copy of the corporate charter, corporate income tax fling return and any other documents(s) to
verify the location of the firm's oftiec.
City of Miami Page 46
Bid No. 05-06-036
4.7. STATEMENT OF NO BID
NOTE: If you do not intend to submit a bid on this commodity or service, please return this form in the bid envelope
on or before bid opening. Failure to submit a response after three (3) times without a sufficient justification
of"No Bid" will be cause for removal from the vendor/bidder's list.
Office of the City Clerk
3 500 Pan American Drive
Miami, FL33131-5504
rs gned,,........ e a nB............ ._.....f.....:.... ERG NCYVEH.ICLE
We, the undersigned, have➢� for thefollowiribid on your Bid No. 05-06-035 for EMERGENCY ...
declined to submit a
UXPMENT-CITYWIDE reasons:
Specifications too "tight", i.e., geared toward one brand or manufacturer only (explain below).
Insufficient time to respond to the Invitation for Bids
We do not offer this product or service.
Our schedule would not permit us to perform.
We are unable to meet specifications.
We are unable to meet bond requirements.
Specifications are unclear (explain below).
We are unable to meet insurance requirements.
Remove us from your bidders' list for this commodity or service.
Other (specify below).
Remarks:
ti
We understand that if this statement is not completed and returned, our company may be deleted from the City of
Miami bidders' list for this commodity or service.
Cornpany Name:
Signature:
Title:
Telephone:
Date:
Wht 1i 1O 5;oeljt
n/ ;2-/o 6
A completed vendor application should be returned with this form if vendor has not previously submitted an
application and secured a vendor number from the City.
City of Miami Page 47
I3id No. 05-06-035
4.8. STATEMENT OF INTENT TO COMPLY WITH ORDINANCE NO. 10032
Bidder certifies that (s)he has read and understood the provisions of City of Miami Ordinance No. 10032, pertaining
to the implementation of a "First Source Hiring Agreement".
Bidder will complete and submit the following questions as part of the IFB. Evaluation of bidder's responsiveness to
Ordinance No. 10032 may be a consideration in the award of a contract.
Violations of this Ordinance may be considered cause for annulment of a contract between the successful bidder and
the City of Miami.
A. Do you expect to create new positions in your company in the event your company was awarded this contract by
the City?
Yes No
B. In the event your answer to Question "A" is yes, how many new positions would you create to perform this
work?
C. Please list below the title, rate of pay, summary of duties, number of positions, and expected length or duration
of all new positions which might be created as a result of this award of contract.
1)
2)
3)
4)
5)
6)
7)
8)
z��
port
(Use additional sheets if necessary)
COMPANY NAME:
SIGNATURE/TITLE:
eewii-ge e y 1/.2 t L k. U(
i' DATE:
FAILURE TO COMPLETE, SIGNLAND RETURN THIS FORM MAY DISOtIALIFY THIS BID.
5.0 BID RESPONSE CHECK LIST
City of Miami
Bid No. 05-06-035
Page 48
This checklist is provided to help you conform to all requirements stipulated in this IFB.
1. Bid Certification Form (Form 4.1.)
This form must be completed and signed to validate your bid
2. Bid Form- (Form 4.2.)
This form must be completed and signed by bidder
Bidder. Qualification.Statement.(Forrn.4,3:).............
This form should be completed in its entirety to verify the capability of
bidder to perform/deliver the services/goods specified in the IFB
4. Minority/Women Business Affairs Registration Affidavit, if
applicable (Form 4.4.)
Must be completed only if one or more of the owners in the business
enterprise is at least 51% owned by a Black, Hispanic or Female.
5. Affirmative Action Policy for Equal Employment Opportunity
(Form 4.5.)
Should be completed by Bidder.
G. Office Location Affidavit, if applicable (Form 4.6.)
Section 18-85 of City Ordinance No. 12271, states that the City
Commission may offer to a responsible and responsiveabidder, who
maintains a Local Office, the opportunity of accepting a bid at the low
bid amount, if the original bid amount submitted by the iota! vendor is
not more than ten percent (10%) in, excess of the lowest other
responsible and responsive bidder. (Mint be signed and notarized by
the local bidder, only for use in attesting office location). The City
reserves the right to verify local status.
7. Statement of No Bid, only if applicable (Form 4.7.)
If you do not intend to submit a bid on this commodity or service, please
return this form in the bid envelope on or before bid opening. If the
"Statement of No Bid" form is not completed and returned, your
company may be deleted from the City of Miami bidder's list for this
commodity or service.
8. Statement of Compliance with Ordinance 10032 (Form 4.8.)
This form must be completed and signed by bidder
9. Bid Bond (Form 4.9)
10. Copy of Occupational License
Copy to be included with Bid.
11. Catalogues
Failure to provide catalogues with bid may deem bid non -responsive.
Required to be
Submitted with
Bid
Yes ® No ❑
Yes Z No ❑
Yes ® No ❑
Yes ®No❑
Yes ® No ❑
Yes ® No El
Yes ®No❑
Yes ® No ❑
Yes ❑ No El
Yes ® No ❑
Yes ® No ❑
TO BE SUBMITTED AS PART OF YOUR BID RESPONSE.
City of Miami Page 49
Bid No. 05-06-035