LITIGATION STATEMENT CHECK ONE [ ] The undersigned bidder has had no litigation and/or judgments entered against it by any local, state or federal entity and has had no litigation and/or judgments entered against such entities during the past ten (10) years. [ ] The undersigned bidder, BY ATTACHMENT TO THIS FORM, submits a summary and disposition of individual cases of litigation and/or judgments entered by or against any local, state or federal entity, by any state or federal court, during the past ten (10) years. COMPANY NAME AUTHORIZED SIGNATURE NAME (PRINT OR TYPE) TITLE Failure to check the appropriate blocks above may result in disqualification of your bid. Likewise, failure to provide documentation of a possible conflict of interest, or a summary of past litigation and/or judgments, may result in disqualification of your bid. E VERIFICATION CERTIFICATION Contract No.Y20-1058-MV I hereby certify that I will utilize the U.S. Department of Homeland Security’s E-Verify system in accordance with the terms governing the use of the system to confirm the employment eligibility of the individuals classified below. In accordance with s. 837.06, Florida Statutes, I understand and acknowledge that whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his or her official duties shall be guilty of a misdemeanor in the second degree, punishable as provided in s. 775.082 or s. 775.083, Florida statutes. All persons, including subcontractors and their workforce, who will perform work under Contract No.Y20-1058-MV, Heavy Equipment Parts and Labor, within the state of Florida. NAME OF CONTRACTOR: ADDRESS OF CONTRACTOR: AUTHORIZED SIGNATURE: TITLE: DATE: RELATIONSHIP DISCLOSURE FORM FOR USE WITH PROCUREMENT ITEMS, EXCEPT THOSE WHERE THE COUNTY IS THE PRINCIPAL OR PRIMARY BIDDER For procurement items that will come before the Board of County Commissioners for final approval, this form shall be completed by the Bidder and shall be submitted to the Procurement Division by the Bidder. In the event any information provided on this form should change, the Bidder must file an amended form on or before the date the item is considered by the appropriate board or body. Part I INFORMATION ON BIDDER: Legal Name of Bidder: Business Address (Street/P.O. Box, City and Zip Code): Business Phone: ( ) Facsimile: ( ) INFORMATION ON XXXXXX’S AUTHORIZED AGENT, IF APPLICABLE: (Agent Authorization Form also required to be attached) Name of Bidder’s Authorized Agent: Business Address (Street/P.O. Box, City and Zip Code): Business Phone: ( ) Facsimile: ( ) Part II IS THE BIDDER A RELATIVE OF THE MAYOR OR ANY MEMBER OF THE BCC? YES NO IS THE MAYOR OR ANY MEMBER OF THE BCC THE BIDDER’S EMPLOYEE? YES NO IS THE BIDDER OR ANY PERSON WITH A DIRECT BENEFICIAL INTEREST IN THE OUTCOME OF THIS MATTER A BUSINESS ASSOCIATE OF THE MAYOR OR ANY MEMBER OF THE BCC? YES NO If you responded “YES” to any of the above questions, please state with whom and explain the relationship. (Use additional sheets of paper if necessary) Part III
CERTIFICATION STATEMENT Under Section 231.006, Family Code, the vendor or applicant certifies that the individual or business entity named in this contract, bid, or application is not ineligible to receive the specified grant, loan, or payment and acknowledges that this contract may be terminated and payment may be withheld if this certification is inaccurate. The contractor understands that it is the contractor’s responsibility to verify whether a child support obligor who is more than 30 days delinquent is the sole proprietor, partner, shareholder or owner with an ownership interest of at least 25%.
Mission Statement a. Employees are the most valuable resource in the City’s effective and efficient delivery of services to the public. The parties have a commitment to prevent drug or alcohol impairment in the workplace and to xxxxxx and maintain a drug and alcohol free work environment. The parties also have a mutual interest in preventing accidents and injuries on the job and, by doing so, protecting the health and safety of employees, co-workers, and the public.
Registration Statement The Registration Statement shall have become effective under the Securities Act and no stop order suspending the effectiveness of the Registration Statement shall have been issued and no proceedings for that purpose shall have been initiated or threatened by the SEC.
Certificate of Interested Parties Form – Form 1295 As required by Section 2252.908 of the Texas Government Code. H-GAC will not enter a Contract with Contractor unless (i) the Contractor submits a disclosure of interested parties form to H-GAC at the time the Contractor submits the contract H-GAC, or
NON-DISCRIMINATION STATEMENT x. Xxxxxxx University does not discriminate with regard to race, color, sex, sexual orientation, disability, age, veteran status, national origin, religion, or political affiliation in the administration of its educational programs, activities, admission or employment practices.
Certification Status The Engineer certifies that it is not:
Antitrust Certification Statements (Tex Government Code § 2155.005) By submission of this bid or proposal, the Bidder certifies that: I affirm under penalty of perjury of the laws of the State of Texas that: (1) I am duly authorized to execute this contract on my own behalf or on behalf of the company, corporation, firm, partnership or individual (Company) listed below; (2) In connection with this bid, neither I nor any representative of the Company has violated any provision of the Texas Free Enterprise and Antitrust Act, Tex. Bus. & Comm. Code Chapter 15; (3) In connection with this bid, neither I nor any representative of the Company has violated any federal antitrust law; (4) Neither I nor any representative of the Company has directly or indirectly communicated any of the contents of this bid to a competitor of the Company or any other company, corporation, firm, partnership or individual engaged in the same line of business as the Company.
Initial Members The initial Members of the LLC, their initial capital contributions, and their percentage interest in the LLC are as follows: Members Percentage Interest in LLC Capital Contribution (If any)
Problem/ Solution Statement Problem California’s forest health crisis is an emergency of unprecedented scope and scale, with disastrous implications for the state’s environment, economy, energy systems, and human life. Unlike essentially all other technologies and solutions proposed to respond to the crisis, gasification has the potential to process forest waste in a way that extracts value and sequesters a large portion of its carbon. Before the recipient’s development of the pre- commercial Powertainer technology, no one had developed gasification technology that could economically respond to the problem. As a result, there have not yet been any large-scale deployments of distributed, commercial-scale gasification technology. The acceleration of tree mortality and persistent drought conditions make finding solutions to this problem more critical with each passing day.
