LCISD WAN RFP
Signed Notice Forms
CERTIFICATION SHEET
In order for a proposal to be considered, the following information must be provided.
FAILURE TO COMPLETE MAY RESULT IN DISQUALIFICATION
Company Name _________________________________________________________________________________
Mailing Address ________________________________________________________________________________
City________________________________________________State__________________________Zip_________
Telephone ____________________________ Fax ___________________________Email address _______________________________________
In business under present name ___________ years and ___________ months
COMPLETE THE APPROPRIATE SECTION BELOW:
|RESIDENT BIDDER |
|"Resident bidder" refers to a person whose principal place of business is in this state, including a contractor whose ultimate parent company or majority owner has |
|its principal place of business in this state. |
| |
|I CERTIFY THAT MY COMPANY IS A "RESIDENT BIDDER": |
|MR. MRS. MS. _______________________________________________________________________________________________ |
|(Circle One) NAME (PLEASE PRINT) |
|POSITION _____________________________________________________________________________________________________ |
|SIGNATURE _______________________________________ DATE _______________________________________ |
OR
|NONRESIDENT BIDDER |
|"Nonresident bidder" refers to a person who is not a resident. |
|IF YOU QUALIFY AS A "nonresident bidder", you must furnish the following information: |
|What is your resident state? (The state your principal place of business is located.) _______________________________________ |
|Does your "residence state" require bidders whose principal place of business is in Texas to underbid vendors whose residence state is the same as yours by a |
|prescribed amount or percentage to receive a comparable contract? "Residence state" means the state in which the principal place of business is located. |
| |
|YES _______ NO _______ If “YES”, What is that amount or percentage? _____________ % |
| |
|I CERTIFY THAT MY COMPANY IS A “NONRESIDENT BIDDER” AND THE ABOVE INFORMATION IS TRUE AND CORRECT: |
|MR. MRS. MS. _______________________________________________________________________________________________ |
|(Circle One) NAME (PLEASE PRINT) |
|POSITION _____________________________________________________________________________________________________ |
|SIGNATURE _______________________________________________________ DATE ____________________________________ |
REFERENCES
FINANCIAL STABILITY must be demonstrated by each Bidder as well as a reliable delivery record. Include a list of at least three (3) accounts that have utilized your products for a minimum of one year.
1._________________________ ______________________ _________________________________________
NAME OF FIRM TELEPHONE REPRESENTATIVE
2._________________________ ______________________ __________________________________________
NAME OF FIRM TELEPHONE REPRESENTATIVE
3._________________________ ______________________ __________________________________________
NAME OF FIRM TELEPHONE REPRESENTATIVE
4._________________________ ______________________ __________________________________________
NAME OF FIRM TELEPHONE REPRESENTATIVE
5._________________________ ______________________ __________________________________________
NAME OF FIRM TELEPHONE REPRESENTATIVE
CONTACT INFORMATION
ADDRESS TO SEND ORDERS: REMIT TO ADDRESS:
(If different from order address)
____________________________ _____________________________
Company Name Company Name
____________________________ _____________________________
Address Address
____________________________ _____________________________
City, State, Zip City, State, Zip
____________________________ _____________________________
Phone # Phone #
____________________________ _____________________________
Fax # Fax #
____________________________ _____________________________
Contact name/department Contact name/department
CERTIFICATION REGARDING LOBBYING
CERTIFICATION FOR CONTRACTS, GRANTS, LOANS,
AND COOPERATIVE AGREEMENTS
The undersigned certifies, to the best of his or her knowledge and belief, that:
(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.
(2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying", in accordance with its instruction.
(3) The undersigned shall require that the language of this certification be included in the award documents for all sub awards at all tiers (including subcontracts, sub grants and contracts under grants, loans, and cooperative agreements) and that all sub recipients shall certify and disclose accordingly.
This certification is a material representation of fact upon which reliance was placed when this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, US Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.
_______________________________________ ________________________________________
Company Authorized Representative (Print)
_______________________________________ ________________________________________
Signature Date
Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion-Lower Tier Covered Transactions
_______________________________ ______________________________________________
U.S Department of Agriculture
This certification is required by the regulations implementing Executive Order 12549, Debarment and Suspension, 7 CFR Part 3017, Section 3017.510, Participants’ responsibilities. The regulations were published as Part IV of the January 30, 1989, Federal Register (pages 4722-4733). Copies of the regulations may be obtained by contacting the Department of Agriculture agency with which this transaction originated.
(Before completing certification, read the instructions below.)
Please check one choice below:
← The prospective lower tier participant certifies, by submission of this proposal, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency.
← When the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal.
_____
Organization Name
______
Name and Title of Authorized Representative
_____
Signature Date
Instructions For Suspension/Debarment Certification Statement
1. By signing and dating the certification statement, the bidder certifies that neither it nor any of its principals (e.g., key employees) has been proposed for debarment, debarred or suspended by a federal agency on the date signed.
2. The prospective bidder shall provide immediate written notice to the person to which this proposal is submitted if at any time the prospective bidder learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.
3. Federal and State penalties exist for vendors and districts that knowingly enter into contracts with suspended/debarred persons.
Felony Conviction Notification
I, the undersigned for the firm named below, certify that the information concerning notification of felony convictions has been reviewed by me and the following information furnished is true to the best of my knowledge.
Name of Vendor:
(please type or print)
Name of Company Official:
(please type or print)
* * * * * * * * * * * * * * * * * * * * * *
A. My firm is a publicly held corporation; therefore, this reporting requirement is not applicable.
Signature of authorized agent: ___________________________ Date: __________
B. My firm is not owned or operated by anyone who has been convicted of a felony.
Signature of authorized agent: ___________________________ Date: __________
C. My firm is owned or operated by the following individuals who has/have been convicted of a
felony.
Name of individual (s):
Details of conviction (s):
Signature of authorized agent: ___________________________ Date: __________
ACKNOWLEDGEMENT FORM
Having carefully read the Standard Terms and Conditions and any Special Conditions listed in this document, the undersigned hereby agrees to furnish all goods and services specified on the Katy ISD Proposal Form at the prices and transportation costs as proposed.
By submission of this proposal, the undersigned certifies that:
a. This proposal has been independently arrived at without collusion with any other bidder or any other competitor;
b. This proposal has not been knowingly disclosed and will not be knowingly disclosed, to any other bidder, competitor or potential competitor, prior to the opening of bids, or proposals for this project;
c. No attempt has been or will be made to induce any other person, partnership or corporation to submit or not submit a proposal;
d. The undersigned certifies that he is fully informed regarding the accuracy of the statements contained in this certification, and the penalties herein are applicable to the bidder as well as to any person signing in his/her behalf;
e. Vendor warrants it has no interest, and shall acquire no interest that would directly or indirectly conflict in any manner or degree with the performance of this proposal. For violation or breach of this warranty, Katy ISD shall have the right to annul this contract without liability:
f. As required by Local Government Code 176.006, the undersigned acknowledges the requirement of filing a Conflict of Interest Questionnaire if there are any facts that would require such to be filed, and acknowledges the fact that the CIQ form is available for download at services/purchasing.htm. or can be obtained directly from the Katy ISD Purchasing Office, 5364 Franz Road, Katy, Texas 77493.
g. The undersigned certifies that to his/her knowledge no Katy ISD employee has any personal or beneficial interest whatsoever in this service or property described herein.
Respondent acknowledges receipt of Addenda number ___ through ___ and has incorporated the provisions therefore into this proposal.
______________________________________________________________________________
AUTHORIZED SIGNATURE PRINT NAME
______________________________________________________________________________
TITLE DATE
CONFLICT OF INTEREST QUESTIONNAIRE
FORM CIQ
Notice to Vendors:
Pursuant to the Texas Local Government Code Chapter 176, House Bill 914 (HB 914), effective January 1, 2006, any person or entity who contracts or seeks to contract with KISD for the sale or purchase of property, goods, or services as well as agents of such persons (hereafter referred to as Vendors) are required to file a Conflict of Interest Questionnaire with the District. Each covered person or entity who seeks to or who contracts with KISD is responsible for complying with any applicable disclosure requirements.
The Conflict of Interest Questionnaire must be filed:
• No later than the seventh business day after the date that the Vendor begins contract discussions or negotiations with KISD, or submits to KISD an application, response to a request for proposal or bid, correspondence, or other writing related to a potential agreement with the entity.
• The Vendor also shall file an updated questionnaire not later than September 1 of each year in which a covered transaction is pending, and the seventh business day after the date of an event that would make a statement in the questionnaire incomplete or inaccurate.
CONFLICT OF INTEREST QUESTIONNAIRE Form CIQ
For vendor or other person doing business with local governmental entity
This questionnaire is being filed in accordance with chapter 176 of the Local Government Code by a person doing business with the governmental entity.
By law this questionnaire must be filed with the records administrator of the local government 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 176.006, Local Government Code.
A person commits an offense if the person violates Section 176.006, Local Government Code. An offense under this section is a Class C misdemeanor.
1. Name of person doing business with local governmental entity.
_____________________________________________________________________________________
2. Previously Filed.
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 September 1 of the year for which an activity described in Section 176.006(a), Local Government Code, is pending and not later than the 7th business day after the date the originally filed questionnaire becomes incomplete or inaccurate.)
3. Describe each affiliation or business relationship with an employee or contractor of the local governmental entity who makes recommendations to a local government officer of the local governmental entity with respect to expenditure of money.
_____________________________________________________________________________________
_____________________________________________________________________________________
4. Describe each affiliation or business relationship with a person who is a local government officer and who appoints or employs a local government officer of the local governmental entity that is the subject of this questionnaire.
_____________________________________________________________________________________
_____________________________________________________________________________________
CONFLICT OF INTEREST QUESTIONNAIRE Form CIQ
For vendor or other person doing business with local governmental entity Page 2
5. Name of local government officer with whom filer has affilitation or business relationship. (Complete this section only if the answer to A, B, or C is YES.)
This section, item 5 including subparts A, B, C & D, must be completed for each officer with whom the filer has affiliation or business relationship. 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 from the filer of the questionnaire?
Yes No
B. Is the filer of the questionnaire receiving or likely to receive taxable income from or at the direction of the local government officer named in this section AND the taxable income is not from the local governmental entity?
Yes No
C. Is the filer of this questionnaire affiliated with a corporation or other business entity that the local government officer serves as an officer or director, or holds an ownership of 10 percent or more?
Yes No
D. Describe each affiliation or business relationship.
_____________________________________________________________________________________
_____________________________________________________________________________________
6. Describe any other affiliation or business relationship that might cause a conflict of interest.
_____________________________________________________________________________________
_____________________________________________________________________________________
7. Signatures.
_____________________________________________________________________________________
Signature of person doing business with the governmental entity Date
I affirm, to the best of my knowledge, this proposal has been arrived at independently and is submitted without collusion with anyone.
I hereby certify that this proposal is prepared and submitted in accordance with the terms and conditions specified in the Request For Proposal Document.
Disclosure: Please list below any owner or employee who is a KISD Board member, related to a Board member, or is an employee of KISD.
Name ________________________________ Relationship to KISD __________________________
Signature: _____________________________Title ________________________________________
Name of Authorized Representative (Printed/Typed) _______________________________________
Company/Organization ______________________________________________________________
Mailing Address _________________________________________________________________
Phone Number ____________________________ Fax Number ______________________________
NO BID NOTIFICATION
KISD is interested in receiving competitive pricing on all items it proposes. We place significant value on quality vendors and we also desire to keep your firm as a proposer and a supplier of materials, equipment and/or services. Therefore, it is important for us to determine why you are not proposing on this contract item. We will analyze your response and attempt to determine if future changes are necessary in our specification development and procedures.
I/WE DID NOT SUBMIT A BID FOR THE FOLLOWING REASONS:
(Please place an X by one or more of the reasons listed below.)
1. ___ Do not supply the requested product/service.
2. ___ Quantities offered or scope of job is TOO SMALL to be supplied by my company.
3. ___ Quantities offered or scope of job is TOO LARGE to be supplied by my company.
4. ___ Specifications are “too tight” or appear to be written around a proprietary product. (Please elaborate on this item.)
5. ___ Cannot bid against MANUFACTURER on this item.
6. ___ Cannot bid against JOBBER on this item.
7. ___ Time frame for bidding was too short. (Please elaborate on your primary reason for this judgment.)
8.___Other: ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Please indicate whether or not you wish to remain on the KISD proposers list:
_____ I DO wish to remain on the proposer list.
_____ I DO NOT wish to remain on the proposer list.
___________________________________________________ ____________
VENDOR SIGNATURE DATE
___________________________________________________ ____________
COMPANY NAME RFP TITLE
___________________________________________________ ______________
ADDRESS CITY STATE ZIP A/C-PHONE NO
Appendix C: Katy Campus Addresses
|Number |School Name |School Street Address |City |TX |School Zip |
|101914001 |KATY H S |6331 HWY BLVD |KATY |TX |77494 |
|101914002 |TAYLOR H S |20700 KINGSLAND BLVD |KATY |TX |77450 |
|101914003 |OPPORT AWARENESS CTR |1732 KATYLAND DR |KATY |TX |77493 |
|101914004 |ARTHUR MILLER CAREER CENTER |1734 KATYLAND DR |KATY |TX |77493 |
|101914005 |MAYDE CREEK H S |19202 GROSCHKE RD |HOUSTON |TX |77084 |
|101914007 |CINCO RANCH H S |23440 CINCO RANCH BLVD |KATY |TX |77494 |
|101914009 |MORTON RANCH HIGH SCHOOL |21000 FRANZ RD |KATY |TX |77449 |
|101914010 |SEVEN LAKES HIGH SCHOOL |9251 S FRY RD |KATY |TX |77494 |
|101914012 |H S #7 |6301 S STADIUM LN |KATY |TX |77494 |
|101914041 |KATY J H |5350 FRANZ RD |KATY |TX |77493 |
|101914042 |WEST MEMORIAL J H |22311 PROVINCIAL BLVD |KATY |TX |77450 |
|101914043 |MAYDE CREEK J H |2700 GREENHOUSE RD |HOUSTON |TX |77084 |
|101914044 |MEMORIAL PARKWAY J H |21203 HIGHLAND KNOLLS |KATY |TX |77450 |
|101914045 |T H MCDONALD J H |3635 LAKES OF BRIDGEWATER DR |KATY |TX |77449 |
|101914046 |RODGER & ELLEN BECK J H |5200 S FRY RD |KATY |TX |77450 |
|101914047 |GARLAND MCMEANS JR HIGH |21001 WESTHEIMER PKWY |KATY |TX |77450 |
|101914048 |CINCO RANCH JUNIOR HIGH |23420 CINCO RANCH BLVD |KATY |TX |77494 |
|101914049 |MORTON RANCH JUNIOR HIGH |2498 N MASON RD |KATY |TX |77449 |
|101914050 |BECKENDORFF JUNIOR HIGH |8200 FRY RD |KATY |TX |77494 |
|101914051 |WOODCREEK JUNIOR HIGH |1801 WOOD CREEK BEND LN |KATY |TX |77494 |
|101914052 |Cardiff Junior High |3900 Dayflower Dr. |KATY |TX |77449 |
|101914101 |MAURICE L WOLFE ELEMENTARY |502 ADDICKS HOWELL RD |HOUSTON |TX |77079 |
|101914102 |KATY EL |5726 GEORGE BUSH AVE |KATY |TX |77493 |
|101914103 |WEST MEMORIAL EL |22605 PROVINCIAL BLVD |KATY |TX |77450 |
|101914104 |MEMORIAL PARKWAY EL |21603 PARK TREE LN |KATY |TX |77450 |
|101914105 |ZELMA HUTSELL EL |5360 FRANZ RD |KATY |TX |77493 |
|101914106 |BEAR CREEK EL |4815 HICKORY DOWNS DR |HOUSTON |TX |77084 |
|101914107 |CIMARRON ELEMENTARY |1100 S PEEK RD |KATY |TX |77494 |
|101914108 |DIANE WINBORN EL |22555 PRINCE GEORGE |KATY |TX |77449 |
|101914109 |NOTTINGHAM COUNTRY EL |20500 KINGSLAND BLVD |KATY |TX |77450 |
|101914110 |SUNDOWN EL |20100 SAUMS RD |KATY |TX |77449 |
|101914111 |MAYDE CREEK EL |2698 GREENHOUSE RD |HOUSTON |TX |77084 |
|101914112 |HAZEL S PATTISON EL |19910 STONELODGE |KATY |TX |77450 |
|101914113 |LORAINE T GOLBOW EL |3535 LAKES OF BRIDGEWATER DR |KATY |TX |77449 |
|101914114 |EDNA MAE FIELDER EL |2100 GREENWAY VILLAGE DR |KATY |TX |77494 |
|101914115 |JEANETTE HAYES EL |21203 PARK TIMBERS |KATY |TX |77450 |
|101914116 |MCROBERTS EL |3535 N FRY RD |KATY |TX |77449 |
|101914117 |ROOSEVELT ALEXANDER EL |6161 S FRY RD |KATY |TX |77494 |
|101914118 |JAMES E WILLIAMS ELEMENTARY |3900 S PEEK RD |KATY |TX |77450 |
|101914119 |SUE CREECH ELEMENTARY |5905 S MASON RD |KATY |TX |77450 |
|101914120 |ROBERT KING ELEMENTARY |1901 CHARLTON HOUSE LN |KATY |TX |77493 |
|101914121 |JEAN & BETTY SCHMALZ ELEMENTARY |18605 GREEN LAND WAY |HOUSTON |TX |77084 |
|101914122 |ODESSA KILPATRICK ELEMENTARY |26100 CINCO RANCH BLVD |KATY |TX |77494 |
|101914123 |ROBERTA WRIGHT RYLANDER EL |24831 WESTHEIMER PKWY |KATY |TX |77494 |
|101914124 |JOELLA EXLEY EL |21800 WESTHEIMER PKWY |KATY |TX |77494 |
|101914125 |JACK & SHARON RHOADS EL |19711 CLAY RD |KATY |TX |77449 |
|101914126 |FRANZ EL |2751 N WESTGREEN BLVD |KATY |TX |77449 |
|101914127 |GRIFFIN ELEMENTARY |7800 S FRY RD |KATY |TX |77494 |
|101914128 |Ursula Stephens Elementary |2715 Fry Rd. |KATY |TX |77449 |
|101914129 |WoodCreek Elementary |1155 WoodCreek Ln. |KATY |TX |77494 |
|101914130 |MORTON RANCH ELEMENTARY |2502 MASON RD |KATY |TX |77449 |
|101914131 |BONNIE HOLLAND ELEMENTARY |23720 SEVEN MEADOW PKWY |KATY |TX |77449 |
|101914132 |Stan C. Stanly Elementary |26633 Cinco Terrace Dr. |KATY |TX |77494 |
Appendix D: Map
[pic]
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State of Texas Legislative Senate Bill No. 1, Section 44.034, Notification of Criminal History, Subsection (a), states “a person or business entity that enters into a contract with a school district must give advance notice to the district if the person or owner or operator of the business entity has been convicted of a felony.” The notice must include a general description of the conduct resulting in the conviction of a felony.
Subsection (b) states “a school district may terminate a contract with a person or business entity if the district determines that the person or business entity failed to give notice as required by Subsection (a) or misrepresented the conduct resulting in the conviction. The district must compensate the person or business entity for services performed before the termination of the contract.
This notice is not required of a publicly held corporation
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