Document BIDDER'S STATEMENT OF MBE/WBE/PDBE/DBE/SBE STATUS

Transcription

1 [Short Project Name] Project No. [GFS/CIP/AIP/File No.] BIDDER S STATEMENT OF MBE/WBE/PDBE/DBE/SBE STATUS Document BIDDER'S STATEMENT OF MBE/WBE/PDBE/DBE/SBE STATUS This certifies that the status of the Bidder,, in (Bidder's Name) regard to the City of Houston Code of Ordinances, Chapter 15, Article V, relating to City-wide percentage goals for contracting with Minority and Women-owned Business Enterprises (MWBE) and Disadvantaged Business Enterprises (DBE), Chapter 15, Article VI, relating to City-wide percentage goals for contracting with Persons with Disabilities Business Enterprises (PDBE) and Chapter 15, Article IX, relating to Citywide percentage goals for contracting with a Small Business Enterprise (SBE) is as follows: 1. Bidder (individual, partnership, corporation) is [ ] is not [ ] a Minority Business Enterprise as certified by the Affirmative Action and Contract Compliance Division. 2. Bidder (individual, partnership, corporation) is [ ] is not [ ] a Women-owned Business Enterprise as certified by the Affirmative Action and Contract Compliance Division. 3. Bidder (individual, partnership, corporation) does [ ] does not [ ] declare itself to be a Persons with Disabilities Business Enterprise as defined above. 4. Bidder (individual, partnership, corporation) does [ ] does not [ ] declare itself to be a Disadvantaged Business Enterprise as defined above. 5. Bidder (individual, partnership, corporation) does [ ] does not [ ] declare itself to be a Small Business Enterprise as defined above. Signature: Title: Date: END OF DOCUMENT

2 [Short Project Name] Project No. [GFS/CIP/AIP/File No.] CONTRACTOR SUBMISSION LIST FAIR CAMPAIGN ORDINANCE EXHIBIT D Document Form A CONTRACTOR SUBMISSION LIST CITY OF HOUSTON FAIR CAMPAIGN ORDINANCE The City of Houston Fair Campaign Ordinance makes it unlawful for a Contractor to offer any contribution to a candidate for City elective office (including elected officerselect) during a certain period of time prior to and following the award of the Contract by the City Council. The term Contractor includes proprietors of proprietorships, partners or joint venturers having an equity interest of 10 percent or more for the partnership or joint venture, and officers, directors and holders of 10 percent or more of the outstanding shares of corporations. Submission of a statement disclosing the names and business addresses of each of those persons is required with each Bid/Proposal for a City Contract. See Chapter 18 of the City of Houston Code of Ordinances for further information. This list is submitted under the provisions of Section 18-36(b) of the City of Houston Code of Ordinances in connection with the attached Bid/Proposal of: Firm or Company Name: Firm or Company Address: The firm/company is organized as indicated below. Check one as applicable and attach additional pages if needed to supply the required names and addresses. [ ] SOLE PROPRIETOR Name [ ] A PARTNERSHIP Proprietor Address LIST EACH PARTNER HAVING EQUITY INTEREST OF 10% OR MORE OF PARTNERSHIP (IF NONE STATE NONE ) Name Name [ ] A CORPORATION Partner Partner Address Address LIST ALL DIRECTORS OF THE CORPORATION (IF NONE STATE NONE )

3 [Short Project Name] Project No. [GFS/CIP/AIP/File No.] CONTRACTOR SUBMISSION LIST FAIR CAMPAIGN ORDINANCE Name Name Name Director Director Director Address Address Address LIST ALL OFFICERS OF THE CORPORATION (IF NONE STATE NONE ) Name Name Name Officer Officer Officer Address Address Address LIST ALL INDIVIDUALS OWNING 10% OR MORE OF OUTSTANDING SHARES OF STOCK OF THE CORPORATION (IF NONE STATE NONE ) Name Name Name Owner Owner Owner Address Address Address I certify that I am duly authorized to submit this list on behalf of the firm, that I am associated with the firm in the capacity noted below, and that I have knowledge of the accuracy of the information provided herein. Signature Printed Name Note: This list constitutes a government record as defined by of the Texas Penal Code. Title END OF DOCUMENT

4 [Short Project Name] Project No. [GFS/CIP/AIP/File No.] BIDDER'S STATEMENT OF RESIDENCY Document BIDDER'S STATEMENT OF RESIDENCY The City may not award a contract for general construction, services, or purchases to a Nonresident Bidder unless Nonresident's Bid is lower than the lowest Bid submitted by a responsible Texas Resident Bidder by the same amount that a Texas Resident bidder would be required to underbid the Nonresident Bidder to obtain a comparable contract in the state in which Nonresident's principle place of business is located. 1. This certifies that the Bidder,, is a State of Texas Resident Bidder as defined in TEX. GOVT. CODE ANN (4) (Vernon 1994). Signature Title "Texas Resident Bidder" means a bidder whose principal place of business is in this State, and includes a Contractor whose ultimate parent company or majority owner has its principal place of business in this State. When bidder cannot sign 1, above, proceed to a. is a resident of and is a Nonresident Bidder as defined in TEX. GOVT. CODE ANN (3) (Vernon 1994). Signature Title "Nonresident Bidder" means a bidder whose principal place of business is not in this State, but excludes a contractor whose ultimate parent company or majority owner has its principal place of business in this State. b. The State of have a state statute giving Bidder's resident state Does or Does Not preference to resident bidders. Signature Title If the answer to 2.b is that your state does have a statute giving preference to resident bidders, then you must provide a copy and proceed to A copy of the State of statute is attached. Signature Title Date END OF DOCUMENT

5 [Short Project Name] Project No. [GFS/CIP/AIP/File No.] BIDDER'S STATEMENT OF RESIDENCY ************************************************************************************ Note to Specifier - Do not include this form if the Project will receive federal funding in whole or in part. If used, include reference in Document Supplementary Instructions to Bidders. States that currently penalize out-of-state bidders include, but may not be limited to, Colorado, Illinois, Iowa, Minnesota, Montana, North Dakota, Pennsylvania, and Wyoming. If Low Bidder is a resident of one of these states, consult the City of Houston Legal Department in adjusting the Bid Amount. ************************************************************************************

6 Project No. AFFIDAVIT OF NON-INTEREST Document AFFIDAVIT OF NON-INTEREST BEFORE ME, the undersigned authority, a Notary Public in and for the State of Texas, on this day personally appeared Affiant, who being by me duly sworn on his oath stated that he is Title, of Name of Firm, the firm named and referred to and in the foregoing; and that he knows of no officer, agent, or employee of the City of Houston being in any manner interested either directly or indirectly in such Contract. Affiant's Signature SWORN AND SUBSCRIBED before me on. Date Notary Public in and for the State of TEXAS Print or type name My Commission Expires: Expiration Date END OF DOCUMENT

7 [Short Project Name] Project No. [WBS/CIP/AIP/File No.] AFFIDAVIT OF OWNERSHIP OR CONTROL Document AFFIDAVIT OF OWNERSHIP OR CONTROL

8 ORIG. DEPT.: FILE/I.D. NO.: INSTRUCTION: ENTITIES USING AN ASSUMED NAME SHOULD DISCLOSE SUCH FACT TO AVOID REJECTION OF THE AFFIDAVIT. THE FOLLOWING FORMAT IS RECOMMENDED: CORPORATE/LEGAL NAME DBA ASSUMED NAME. STATE OF AFFIDAVIT OF OWNERSHIP OR CONTROL COUNTY OF BEFORE ME, the undersigned authority, on this day personally appeared [FULL NAME] (hereafter Affiant ), [STATE TITLE/CAPACITY WITH CONTRACTING ENTITY] of [CONTRACTING ENTITY S CORPORATE/LEGAL NAME] ( Contracting Entity ), who being by me duly sworn on oath stated as follows: stated. 1. Affiant is authorized to give this affidavit and has personal knowledge of the facts and matters herein 2. Contracting Entity seeks to do business with the City in connection with [DESCRIBE PROJECT OR MATTER] which is expected to be in an amount that exceeds $50, The following information is submitted in connection with the proposal, submission or bid of Contracting Entity in connection with the above described project or matter. 4. Contracting Entity is organized as a business entity as noted below (check box as applicable). FOR PROFIT ENTITY: NON-PROFIT ENTITY: [ ] SOLE PROPRIETORSHIP [ ] NON-PROFIT CORPORATION [ ] CORPORATION [ ] UNINCORPORATED ASSOCIATION [ ] PARTNERSHIP [ ] LIMITED PARTNERSHIP [ ] JOINT VENTURE [ ] LIMITED LIABILITY COMPANY [ ] OTHER (Specify type in space below) 5. The information shown below is true and correct for the Contracting Entity and all owners of 5% or more of the Contracting Entity and, where the Contracting Entity is a non-profit entity, the required information has been shown for each officer, i.e., president, vice-president, secretary, treasurer, etc. [NOTE: IN ALL CASES, USE FULL NAMES, LOCAL BUSINESS AND RESIDENCE ADDRESSES AND TELEPHONE NUMBERS. DO NOT USE POST OFFICE BOXES FOR ANY ADDRESS. INCLUSION OF ADDRESSES IS OPTIONAL, BUT RECOMMENDED. ATTACH ADDITIONAL SHEETS AS NEEDED.] K:\DEBT\RDC2353A 1

9 Contracting Entity Name: Business Address [NO./STREET] [CITY/STATE/ZIP CODE] Telephone Number ( ) Address [OPTIONAL] Residence Address [NO./STREET] [CITY/STATE/ZIP CODE] Telephone Number ( ) Address [OPTIONAL] 5% Owner(s) or More (IF NONE, STATE NONE. ) Name: Business Address [NO./STREET] [CITY/STATE/ZIP CODE] Telephone Number Address [OPTIONAL] ( ) Residence Address [NO./STREET] [CITY/STATE/ZIP CODE] Telephone Number Address [OPTIONAL] ( ) 2

10 6. Optional Information Contracting Entity and/or [NAME OF OWNER OR NON- PROFIT OFFICER] is actively protesting, challenging or appealing the accuracy and/or amount of taxes levied against [CONTRACTING ENTITY, OWNER OR NON-PROFIT OFFICER] as follows: Name of Debtor: Tax Account Nos. Case or File Nos. Attorney/Agent Name Attorney/Agent Phone No. ( ) Tax Years Status of Appeal [DESCRIBE] Affiant certifies that he or she is duly authorized to submit the above information on behalf of the Contracting Entity, that Affiant is associated with the Contracting Entity in the capacity noted above and has personal knowledge of the accuracy of the information provided herein, and that the information provided herein is true and correct to the best of Affiant s knowledge and belief. Affiant (Seal) SWORN TO AND SUBSCRIBED before me this day of, 20. Notary Public NOTE: This affidavit constitutes a government record as defined by Section of the Texas Penal Code. Submission of a false government record is punishable as provided in Section of the Texas Penal Code. Attach additional pages if needed to supply the required names and addresses. 3

11 [Short Project Name] Project No. [GFS/CIP/AIP/File No.] CONFLICT OF INTEREST QUESTIONNAIRE Document Conflict of Interest Questionnaire ************************************************************************************************ Print out latest version (Amended 06/29/2007 or later) of the CIQ form from website listed below: ************************************************************************************************ Local Government Code Chapter 176 requires Bidders with the City of Houston ( City ) to file a Conflict of Interest Questionnaire with the City Secretary of the City of Houston. The Conflict of Interest Questionnaire is available for downloading on the Texas Ethics Commission s website at: The completed Conflict of Interest Questionnaire will be posted on the City Secretary s website. Also you will find a list of the City Local Government Officers on the City Secretary s website. For your convenience the CIQ form is attached as part of this document. Although the City has provided this document for the Bidders convenience, it is the Bidders responsibility to submit the latest version of the CIQ form as promulgated by the Texas Ethics Commission. The Failure of any Bidder to comply with this law is a Class C misdemeanor. END OF DOCUMENT

12 CONFLICT OF INTEREST QUESTIONNAIRE For vendor or other person doing business with local governmental entity This questionnaire reflects changes made to the law by H.B. 1491, 80th Leg., Regular Session. This questionnaire is being filed in accordance with Chapter 176, Local Government Code by a person who has a business relationship as defined by Section (1-a) with a local governmental entity and the person meets requirements under Section (a). By law this questionnaire must be filed with the records administrator of the local governmental entity not later than the 7th business day after the date the person becomes aware of facts that require the statement to be filed. See Section , Local Government Code. A person commits an offense if the person knowingly violates Section , Local Government Code. An offense under this section is a Class C misdemeanor. FORM CIQ OFFICE USE ONLY Date Received 1 Name of person who has a business relationship with local governmental entity. 2 Check this box if you are filing an update to a previously filed questionnaire. (The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than the 7th business day after the date the originally filed questionnaire becomes incomplete or inaccurate.) 3 Name of local government officer with whom filer has employment or business relationship. Name of Officer This section (item 3 including subparts A, B, C & D) must be completed for each officer with whom the filer has an employment or other business relationship as defined by Section (1-a), Local Government Code. Attach additional pages to this Form CIQ as necessary. A. Is the local government officer named in this section receiving or likely to receive taxable income, other than investment income, from the filer of the questionnaire? Yes No B. Is the filer of the questionnaire receiving or likely to receive taxable income, other than investment income, from or at the direction of the local government officer named in this section AND the taxable income is not received from the local governmental entity? Yes No C. Is the filer of this questionnaire employed by a corporation or other business entity with respect to which the local government officer serves as an officer or director, or holds an ownership of 10 percent or more? Yes No D. Describe each employment or business relationship with the local government officer named in this section. 4 Signature of person doing business with the governmental entity Date Adopted 06/29/2007

13 Form POP- 1 City of Houston Pay or Play Program Acknowledgement Form It has been determined that the project currently open for bidding meets the criteria of the City of Houston Pay or Play program. This form acknowledges your awareness of the Pay or Play program which is authorized by Ordinance Your signature below affirms that you will comply with the requirements of the program if you are the successful bidder/proposer, and ensure the same on behalf of subcontracts subject to the Pay or Play Program. I declare under penalty of perjury under the laws of the State of Texas that if awarded this contract which meets the criteria for the City of Houston s Pay or Play Program, I will comply with all requirements of the Pay or Play Program in accordance with Executive Order 1-7. *Fill out all information below and submit this form with your bid/proposal packet. Solicitation Number Signature Date Print Name City Vendor ID Company Name Phone Number Address Note: For more information contact your POP Liaison or the POP Contract Administrator. All contact information can be found on Departments Office of Business Opportunity Pay or Play. Document OBO 7/3/2012

14 Hire Houston First Application and Affidavit Thank you for your interest in the Hire Houston First initiative. It is the policy of the City of Houston as defined in Chapter 15, Article XI, to use the City s spending powers in a manner that promotes fiscal responsibility and maximizes the effectiveness of local tax dollars by ensuring a portion of citizens tax dollars remain in the local economy for economic benefit of the citizens by utilizing all available legal opportunities to contract with city and/or local businesses. Businesses interested in becoming eligible to participate in the Hire Houston First initiative must complete this application and sign the attached affidavit. Only businesses that meet the requirements will be eligible to participate in the Hire Houston First initiative. A completed HHF application is NOT evidence of designation under the Hire Houston First initiative. An applicant s eligibility must be confirmed in writing by the Office of Business Opportunity. Definitions: A. City Business means a business with a principal place of business within city limits. B. Local Area means eight counties in and surrounding Houston city limits. The counties are Harris, Fort Bend, Montgomery, Brazoria, Galveston, Chambers, Waller, and Liberty. C. Local Business means a business with a principal place of business in the local area. D. Principal place of business means the business must be headquartered or have an established place or places of business in the incorporated limits of the city or the local area as applicable, from which 20% or more of the entity s workforce are regularly based, and from which a substantial role in the entity s performance of a commercially useful function or a substantial part of its operations is conducted. A location utilized solely as a post office box, mail drop or telephone message center or any combination thereof, with no other substantial work function, shall not be construed as a principal place of business. E. Headquartered means the location where an entity s leadership directs, controls, and coordinates the entity s activities. Application Please complete the following form/affidavit and submit it to the Office of Business Opportunity, Houston Business Solutions Center located at 611 Walker, Lobby Level, Houston, TX (832) Applications may be submitted via to houstonbsc@houstontx.gov or faxed to Incomplete applications and affidavits will not be processed. Please answer all questions. 1. Application Date: 2. Company is applying as (please check at least one box): City Business (CB) with a principal place of business within the city limits from which a substantial role in the entity s performance of a commercially useful function or a substantial part of its operations is conducted as defined in Chapter 15, Article XI. Local Business (LB) with a principal place of business in the local area from which a substantial role in the entity s performance of a commercially useful function or a substantial part of its operations is conducted as defined in Chapter 15, Article XI. 3. Name of Owner or CEO: Name of Company: FOR OFFICE USE ONLY: 1 Revised 10/23/2012

15 4. Business Address(for use in determining HHF eligibility): 5. Mailing Address(If different from Business Address): Street City State Zip Code Street City State Zip Code 6. Business Phone Number: Business Fax Number: 7. Business Business Website: 8. Federal Tax ID Number: COH Vendor Registration ID Number: 9. Describe the primary activities of your firm: 10. In accordance with the aforementioned definition for headquartered, is your company s headquarters or corporate office located in one of the following eight counties? YES NO If yes, check all that apply. Harris Brazoria Chambers Fort Bend Galveston Liberty Montgomery Waller How many employees are based within the county or counties you selected? If you answered no to question 10, please answer questions 11, 12 and What is the number of employees that are based within the following eight counties? Harris Brazoria Chambers Fort Bend Galveston Liberty Montgomery Waller 12. List all company locations inside city limits and in the 8 county local area as well as addresses, primary activities and number of employees at each location. Business Address Primary Activities Number of Employees Business Name: Street Address: City, State: Zip Code: Main Phone Number: Business Name: Street Address: City, State: Zip Code: Main Phone Number: Business Name: Street Address: City, State: Zip Code: Main Phone Number: 2 Revised 10/23/2012

16 Business Address Primary Activities Number of Employees Business Name: Street Address: City, State: Zip Code: Main Phone Number: 13. List all company locations OUTSIDE the eight (8) county local area, including headquarters locations, as well as addresses, primary activities and number of employees at each location. Business Address Corporate Primary Activities Number of Headquarters? Employees Business Name: Street Address: City, State: YES/NO Zip Code: Main Phone Number: Business Name: Street Address: City, State: YES/NO Zip Code: Main Phone Number: Business Name: Street Address: City, State: YES/NO Zip Code: Main Phone Number: Business Name: Street Address: City, State: YES/NO Zip Code: Main Phone Number: Business Name: Street Address: City, State: YES/NO Zip Code: Main Phone Number: 14. What is the total number of employees in the entire company? 15. Is the company represented on this application an independent or dependent subsidiary of a company with headquarters located outside the eight county local area? (Check One) NOT a subsidiary of any company YES An independent subsidiary. Please submit Federal corporate tax returns and any other documentation necessary to show independence from the parent company. YES A dependent subsidiary. Please answer the following questions: (a). What is the total number of employees within the (8) county local area inclusive of the company represented on this application and the parent company? (b). What is the total number of all employees inclusive of the company represented on this application and the parent company? 3 Revised 10/23/2012

17 Hire Houston First Affidavit I certify and affirm that my business is not Name of Company Owner Name of Company a location utilized solely as a post office box, mail drop or telephone message center or any combination thereof, with no other substantial work function. The undersigned swear/affirm that the foregoing information and statements are true and correct with regard to the employee breakdown of the company s work force, location, and principal place of business. In addition, the undersigned gives permission to the City of Houston to conduct random audits to ensure compliance with the Hire Houston First Initiative under Chapter 15, Article XI. Name of Company Owner Name of Company On this day before me appeared (name) with proper identification, who being duly sworn, did execute the foregoing affidavit and did aver that he or she was properly authorized to execute this affidavit and did so as his or her free act/deed. Signature (Owner /Applicant) Title Name (Print) Date (Seal) Notary Attest: Notary Public Commission Expiration 4 Revised 10/23/2012

18 <<ShortPrjName>> WBS NO. «WBSNo» BIDDER S MWSBE PARTICIPATION PLAN Document BIDDER S MWSBE PARTICIPATION PLAN The Bidder or Proposer shall submit this completed form with the bid, to demonstrate the Bidder/Proposer s plan to meet the contract-specific MWSBE goal ( contract goal ). If the Bidder or Proposer cannot meet the contract goal, the Bidder/Proposer has the burden to demonstrate Good Faith Efforts, which shall include correctly and accurately preparing and submitting this form, a Record of Good Faith Efforts (Document 00471), a Request for Deviation from the Goal (Document 00472), and providing supporting documentation evidencing their Good Faith Efforts, as required by the City of Houston s Good Faith Efforts Policy (Document 00808). The City will review the Participation Plan and Good Faith Efforts at the time of bid opening. Visit for more information. City Contract Goal MBE WBE MBE and WBE Goals are two separate Contract Goals. Any excess of one Goal cannot be applied to meet another Goal. An SBE can be applied to the MBE and/or WBE Goal, but not to exceed 4%. NAICS Code (6 digit) Description of Work (Plan Sheet #, Unit Price #, Scope of Work #, as applicable) % of Total Bid Price (2 decimal places; for example, 5.00%) Cert. Type for Goal: MBE, WBE, or SBE Certified Firm Name Firm Address Contact Name Phone No. and MBE WBE SBE MBE WBE SBE MBE WBE SBE MBE WBE SBE MBE WBE SBE MBE WBE SBE MBE WBE SBE Bidder s Participation Plan Total MBE WBE SBE Signature for Company: * Printed Name: Company Name: Phone #: *I understand that supplying inaccurate information may violate Texas Penal Code Section and lead to City sanctions. Date: <<Bidder or Proposer Name>>

19 <<ShortPrjName>> WBS NO. «WBSNo» BIDDER S MWSBE PARTICIPATION PLAN Document CONTINUATION PAGE NAICS Code (6 digit) Description of Work (Plan Sheet #, Unit Price #, Scope of Work #, as applicable) % of Total Bid Price (2 decimal places; for example, 5.00%) Cert. Type for Goal MBE, WBE, or SBE MBE WBE SBE Certified Firm Name Firm Address Contact Name Phone No. and MBE WBE SBE MBE WBE SBE MBE WBE SBE MBE WBE SBE MBE WBE SBE MBE WBE SBE MBE WBE SBE MBE WBE SBE MBE WBE SBE MBE WBE SBE MBE WBE SBE Signature for Company: * Date: Print Name/Company Name: Phone: *I understand that supplying inaccurate information may violate Texas Penal Code Section and lead to City sanctions <<Bidder or Proposer Name>>

20 [Short Project Name] WBS No. [WBS No.] PRE-BID GOOD FAITH EFFORTS Document PRE-BID GOOD FAITH EFFORTS Bidder Name: Project Name A Bidder or Proposer that may be unable to complete or follow a Participation Plan (Document 00470) to meet the Contract Goal in the Supplemental Conditions (Document 00800), must submit this completed form, Goal Deviation Request Form (Document 00472), providing supporting documentation evidencing their Good Faith Efforts, as required by the City of Houston s Good Faith Efforts Policy (see Document 00808). The Bidder or Prime Contractor has the burden to demonstrate Good Faith Efforts to meet the MWSBE goal, which includes correctly and accurately preparing and submitting this form and other efforts described in the City s Good Faith Efforts Policy (Document 00808). The Office of Business Opportunity will review Good Faith Efforts and Participation Plan after selection of an apparent low bidder. UNLESS THE BIDDER S/PROPOSER S PARTICIPATION PLAN MEETS THE CONTRACT GOAL, FAILURE TO SUBMIT THIS FORM MAY RESULT IN THE BID BEING FOUND NON-RESPONSIVE. NAICS Code Plan Item No. MWSBE Type for Goal MBE WBE SBE Certified Firm Name Address, Phone No., and Certified Firm Contact Person Methods of Contact Phone Fax Prime Contac t Dates Certified Firm Respons e Results of Contact (why suitable or not suitable for work) MBE WBE SBE Phone Fax MBE WBE SBE Phone Fax MBE WBE SBE Phone Fax Authorized Signature: Date: Phone: Print Name: Address: Company Name:

21 [Short Project Name] WBS No. [WBS No.] PRE-BID GOOD FAITH EFFORTS CONTINUATION PAGE NAICS Code Plan Item No. MWSBE Type for Goal MBE WBE SBE MBE WBE SBE Certified Firm Name Address, Phone No., and Certified Firm Contact Person Method of Contac t Phone Fax Phone Fax Prime Contac t Dates Certified Firm Respons e Results of Contact (why suitable or not suitable for work) MBE WBE SBE MBE WBE SBE MBE WBE SBE MBE WBE SBE Phone Fax Phone Fax Phone Fax Phone Fax MBE WBE SBE Phone Fax Authorized Signature: Date: Phone: Print Name: Address: Company Name:

22 [Short Project Name] WBS No. [WBS No.] BIDDER S MWSBE GOAL DEVIATION REQUEST Document BIDDER S MWSBE GOAL DEVIATION REQUEST Company Name: Project Name: Department Approved Contract Goals MBE % WBE % Total % Bidder s Proposed Participation Plan MBE % WBE % SBE (Max 4% for Credit) % Total % Justification: Please provide the reason the Bidder is unable to meet the Contract Goal in Document Good Faith Efforts: Please list any efforts not listed in the Bidder s Pre-Bid Good Faith Effort (Document 00471) and provide supporting documentation evidencing Good Faith Efforts, as required by the City of Houston s Good Faith Efforts Policy (Document 808). Date: Phone Number: Company Name: Company Representative: Title: FOR OFFICIAL USE ONLY: Approved [ ] Not Approved [ ] OBO Representative Date: Title:

23 REFERENCES 1.0 REFERENCES 1.1 In order to receive bid award consideration, the bidder must be able to demonstrate that they are currently providing or have had at least one contract, as a prime contractor, for Subway Train System Operations & Maintenance Services that is similar in size and scope to this contract. Bidder must have references documenting that it has performed Subway Train System Operations & Maintenance Services. 1.2 The reference(s) should be included in the space provided below. Please attach another piece of paper, if necessary. If the references are not included with the bid, the bidder shall be required to provide such references to the City of Houston within five working days from receipt of a written request from the City to do so. Bidder s capability and experience shall be a factor in determining the contract award. LIST OF CURRENT/PREVIOUS CUSTOMERS 1. Company Name: Contact Person/Title: Address: Address: Contract Award Date: Contract Name/Title: Project Description: Phone No.: Contract Completion Date: 2. Company Name: Contact Person/Title: Address: Address: Contract Award Date: Contract Name/Title: Project Description: Contract Completion Date: Phone No.: 3. Company Name: Contact Person/Title: Address: Address: Contract Award Date: Contract Name/Title: Project Description: Contract Completion Date: Phone No.:

24 REFERENCES 4. Company Name: Contact Person/Title: Address: Address: Contract Award Date: Contract Name/Title: Project Description: Contract Completion Date: Phone No.: 5. Company Name: Contact Person/Title: Address: Address: Contract Award Date: Contract Name/Title: Project Description: Contract Completion Date: Phone No.: 6. Company Name: Contact Person/Title: Address: Address: Contract Award Date: Contract Name/Title: Project Description: Contract Completion Date: Phone No.:

25 DOCUMENT ANTI-COLLUSION STATEMENT Anti-Collusion Statement The undersigned, as Proposer, certifies that the only person or parties interested in this Proposal as principals are those named herein; that the Proposer has not, either directly or indirectly entered into any Agreement, participated in any collusion, or otherwise taken any action in restraint of free competitive bidding in connection with the award of this Contract. Date Proposer Signature

26 CERTIFICATE OF INTERESTED PARTIES FORM 1295 Complete Nos. 1-4 and 6 if there are interested parties. Complete Nos. 1, 2, 3, 5, and 6 if there are no interested parties. OFFICE USE ONLY 1 Name of business entity filing form, and the city, state and country of the business entity's place of business. 2 Name of governmental entity or state agency that is a party to the contract for which the form is being filed. 3 Provide the identification number used by the governmental entity or state agency to track or identify the contract, and provide a description of the goods or services to be provided under the contract. 4 Name of Interested Party City, State, Country (place of business) Nature of Interest (check applicable) Controlling Intermediary 5 Check only if there is NO Interested Party. 6 AFFIDAVIT I swear, or affirm, under penalty of perjury, that the above disclosure is true and correct. AFFIX NOTARY STAMP / SEAL ABOVE Signature of authorized agent of contracting business entity Sworn to and subscribed before me, by the said, this the day of, 20, to certify which, witness my hand and seal of office. Signature of officer administering oath Printed name of officer administering oath Title of officer administering oath ADD ADDITIONAL PAGES AS NECESSARY Form provided by Texas Ethics Commission Adopted 10/5/2015