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17-01-17 PURCHASE AND REPAIR OF FORKLIFTS
PART 3 OF 3
Attachments
Please include completed forms with the your submitted proposals and USB flash
drive
Attachments:
FORM A: Vendor Information
FORM B: MWBE Instructions and Participation Report (Separate attachment)
FORM C: Performance Evaluation Survey instructions
FORM D: Performance Evaluation Survey
FORM E: General Certifications
FORM F: Price Schedule (Separate attachment in excel format)
FORM G: EDGAR Certifications
FORM H: Exceptions
FORM I: Conflict of Interest Instructions and Questionnaire (Form CIQ)
FORM J: Instructions for Completion of Disclosure of Interested Persons Certification (HB 1295)
FORM K: IRS Form W‐9
FORM L: Certificate of Insurance (Acord Form) or a letter from its insurance provider stating that
Proposer can provide the levels of insurance required in this RFP.
FORM A: VENDOR INFORMATION
This Form A is required. See HISD Policy CHE (Local). D&B and Safety
LEGAL NAME OF VENDOR: ___________________________________________________________________
DATA UNIVERSAL NUMBERING SYSTEM (DUNS) NUMBER: _____________________________________________
TYPE OF BUSINESS/DESCRIPTION OF PRODUCTS AND/OR SERVICES PROVIDED:
_______________________
___________________________________________________________________
___________________________________________________________________
VENDOR MAILING ADDRESS:
__________________________________________________________________
CITY: _____________________________
VENDOR STREET ADDRESS:
______________ ZIP CODE: ______________________
__________________________________________________________________
CITY: _____________________________
TELEPHONE:
STATE:
STATE:
______________ ZIP CODE: ______________________
__________________________________ FAX: ______________________________________
CONTACT PERSON’S NAME: ___________________________________________________________________
CONTACT PERSON’S TELEPHONE NUMBER: _______________________
FAX: ___________________________
CONTACT PERSON’S E-MAIL ADDRESS: ___________________________________________________________
☐ PUBLICLY TRADED CORPORATION ☐ PRIVATE CORPORATION ☐ LIMITED PARTNERSHIP
☐ PARTNERSHIP ☐ SOLE PROPRIETORSHIP ☐ NOT FOR PROFIT ENTITY
1.
TYPE OF BUSINESS ENTITY:
2.
NUMBER OF FULL TIME EMPLOYEES: _________________
3.
IS VENDOR IS A RESIDENT BIDDER? ☐ YES
☐ NO
A RESIDENT BIDDER REFERS TO A PERSON WHOSE PRINCIPAL PLACE OF BUSINESS IN THE STATE OF TEXAS,
INCLUDING A VENDOR WHOSE ULTIMATE PARENT COMPANY OR MAJORITY OWNER HAS ITS PRINCIPAL PLACE OF
BUSINESS IN THIS STATE.
4.
CITY AND STATE OF VENDOR'S PRINCIPAL PLACE OF BUSINESS: __________________________________________
NUMBER OF PART TIME EMPLOYEES:
IF NOT TEXAS, DOES THE STATE HAVE PREFERENTIAL TREATMENT ON BIDS?
☐ YES
_______________
☐ NO
IF YES, WHAT PERCENTAGE: ____________%
5.
NUMBER OF YEARS VENDOR HAS BEEN IN CONTINUOUS OPERATION:______________________________________
6.
NUMBER OF YEARS VENDOR HAS BEEN IN BUSINESS UNDER ITS PRESENT BUSINESS NAME: _____________________
7.
HAS VENDOR CONDUCTED BUSINESS WITH THE DISTRICT UNDER ANOTHER NAME?
☐ YES
☐ NO
IF YES, PROVIDE OTHER NAME(S):_______________________________________________________
________________________________________________________________________________
8.
NUMBER OF YEARS DOING BUSINESS WITH HISD: __________________________________________________________________
9.
DOES VENDOR HAVE A PARENT COMPANY OR SUBSIDIARY THAT CURRENTLY CONDUCTS OR THAT HAS PREVIOUSLY
CONDUCTED BUSINESS WITH THE DISTRICT?
☐ YES ☐ NO
IF YES, NAME OF PARENT COMPANY AND/OR SUBSIDIARY: ____________________________________________________
______________________________________________________________________________________________
10. DO YOU HAVE EXPERIENCE WITH OTHER SCHOOL DISTRICTS? ☐ YES ☐ NO
IF YES, NAMES OF SCHOOL DISTRICTS___________________________________________________________________
_______________________________________________________________________________________________
11. DOES VENDOR HAVE ANY OWNERS, PRINCIPAL SHAREHOLDERS OR STOCKHOLDERS, OFFICERS, AGENTS, SALESPEOPLE OR KEY EMPLOYEES
WHO HAVE BEEN MEMBERS OF THE HISD BOARD OF EDUCATION DURING THE LAST 5 YEARS?
☐ YES ☐ NO
IF YES, NAME(S) AND TITLE(S): ________________________________________________________________________
12. DOES ANY OFFICER, PARTNER, OWNER, SALES REPRESENTATIVE AND/OR SPOUSE WORK FOR HISD? ☐ YES
☐ NO
13. DOES VENDOR HAVE ANY OWNERS, PRINCIPAL SHAREHOLDERS OR STOCKHOLDERS, OFFICERS, AGENTS, SALESPEOPLE OR KEY EMPLOYEES
WHO ARE DISTRICT EMPLOYEES OR WHO ARE MEMBERS OF A DISTRICT EMPLOYEE’S IMMEDIATE FAMILY WHO EITHER WORK OR WHO MAY
POTENTIALLY WORK ON THIS CONTRACT WITH THE DISTRICT?
☐ YES ☐ NO
IF YES, NAME(S) AND TITLE(S): ________________________________________________________________________
______________________________________________________________________________________________
14. NAMES OF AUTHORIZED AGENTS, INCLUDING ANY PERSON OR ENTITY AUTHORIZED TO ‘ACT WITH’ OR ‘ACT ON YOUR BEHALF,’ SUCH AS
CONSULTANTS, SUB-CONTRACTORS, RE-SELLERS, LOBBYISTS, CONFIDANTS, ETC., WHETHER COMPENSATED OR NOT COMPENSATED:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
15. DOES VENDOR HAVE RELATIONSHIP(S) WITH ANY POLITICAL ACTION COMMITTEES? ☐ YES ☐ NO
IF YES, NAME(S) OF OF PAC(S)_______________________________________________________________________
16. HAS VENDOR (INCLUDING ANY OWNER, PRINCIPAL SHAREHOLDER OR STOCKHOLDER, OFFICER, AGENT, SALESPERSON, OR EMPLOYEE) BEEN
INVOLVED IN PAST, PENDING, OR PRESENT LITIGATION INVOLVING THE DISTRICT?
☐ YES ☐ NO
IF YES, PLEASE PROVIDE THE STYLE AND STATUS OF THE CASE AS WELL AS THE TYPE OF LITIGATION: ____________________
______________________________________________________________________________________________
17. FINANCIAL AND BUSINESS REFERENCES, INCLUDING BANK WITH WHICH VENDOR CONDUCTS BUSINESS:
NAME OF BANK WITH WHICH VENDOR CONDUCTS BUSINESS: __________________________________________________
_
BANK OFFICER: _____________________________ OFFICER’S PHONE NUMBER: _______________________________
NAME OF OTHER BANKING/FINANCIAL INSTITUTION(S): _______________________________________________________
_______________________________________________________
18. NAME OF INSURANCE COMPANIES:
INSURANCE COMPANIES
INSURANCE COMPANIES
19. HISD ENCOURAGES THE PARTICIPATION OF MINORITY AND WOMEN OWNED BUSINESES. IS VENDOR A MINORITY AND/OR WOMAN OWNED
COMPANY? ☐ YES ☐ NO
IF YES, WHAT PERCENTAGE OF OWNERSHIP IS MINORITY OR WOMAN OWNED _____________%
20. CHECK ONE OF THE FOLLOWING:
☐
☐
VENDOR WILL PROVIDE GOODS AND SERVICES WITH OWN WORK FORCE
VENDOR WILL PURCHASE GOODS DIRECTLY FROM THE MANUFACTURER OR OTHER SUPPLIER
21. HISD CAN ONLY DO BUSINESS WITH EQUAL OPPORTUNITY EMPLOYERS.
DO YOU ADVERTISE AS AN EQUAL OPPORTUNITY EMPLOYER?
☐ YES ☐
NO
DO YOU HAVE A WRITTEN NON-DISCRIMINATORY POLICY OF EMPLOYMENT?
☐ YES ☐
NO
HAS THIS POLICY BEEN CIRCULATED THROUGHOUT YOUR ORGANIZATION?
☐ YES ☐
NO
PERSON TO CONTACT REGARDING EQUAL OPPORTUNITY INFORMATION ISSUES:
NAME: _______________________________________ TITLE: ____________________________________
I ATTEST THAT I HAVE ANSWERED THE QUESTIONS REGARDING VENDOR INFORMATION TRUTHFULLY AND TO THE BEST OF MY
KNOWLEDGE.
______________________________________________
OFFICER’S SIGNATURE
______________________________________________
PRINTED NAME
______________________________________________
TITLE
FORM B: MWBE INSTRUCTIONS
Please refer to Separate Attachment B (MWBE) Participation Report and place in Tab 2
FORM C: REFERENCE INFORMATION AND INSTRUCTIONS
Proposer must complete and return Form C as part of its RFP.
The Evaluation Committee considers Proposer’s reputation and reputation of Proposer’s goods or services in
its evaluation of this Proposal.
Proposer to complete FORM C
The District requests the proposer to send FORM D (Proposer Reference) to their respected Clients for
the purpose of their Client to complete.
The proposer’s Client is then to send the completed FORM D to [email protected] (Sr. Sourcing
Specialist), no later than the proposal due date of March 30, 2017 at 2pm CST
Please provide the name and contact information of all references to whom Proposer intends to send the
FORM D (References).
(1) ________________________________________
________________________________________
________________________________________
________________________________________
________________________________________
________________________________________
(2) ________________________________________
________________________________________
________________________________________
________________________________________
________________________________________
________________________________________
(3) ________________________________________
________________________________________
________________________________________
________________________________________
________________________________________
________________________________________
Name of Entity or Business
Mailing Address
Phone Number
Name of Entity or Business
Mailing Address
Phone Number
Name of Entity or Business
Mailing Address
Phone Number
Contact Name
City, State, Zip
Goods and/or services provided
Contact Name
City, State, Zip
Goods and/or services provided
Contact Name
City, State, Zip
Goods and/or services provided
FORM D: PROPOSER’S REFERENCE
This requested reference is for HISD RFP # 17-01-17 – Purchase and Repair of Forklifts
Proposer’s Company Name_________________________________________________________________
HISD requests the company completing this reference request, to send directly to HISD via email to
[email protected] on or before March 30, 2017 at 2pm CST.
(I)
Please evaluate the performance of the Vendor on a scale of one (1) through ten (10), with 10 being the highest. If you do
not have sufficient knowledge of Vendor’s past and/or current performance in a particular area, please leave it blank.
NO.
1
CRITERIA
UNIT
(1-10)
Ability to Manage Cost
2
Quality of Product(s) and/or Services
3
4
Quality of Customer Service
Quick Response Time
(1-10)
(1-10)
(1-10)
5
Ability to Maintain Confidentiality
(1-10)
6
Close Out Process (invoicing, no unexpected fees)
(1-10)
7
Communication
(1-10)
8
Ability to Follow Rules, Regulations, and Requirements
9
10
(1-10)
Overall Customer Satisfaction Based on Performance (comfort level using company
again)
Safety
(1-10)
TOTAL POINTS (out of 100) :
(II)
SCORE
____________
How long have you done business with the Vendor? _______________________________________________________
_____________________________________________________________________________________________
The Houston Independent School District (HISD) has implemented a process to collect Vendor performance evaluations. HISD may
use the information provided in its assessment of the above Vendor in order to determine a responsive and responsible procurement.
The Vendor listed above has chosen to participate in this process and listed you as a past or present client for whom it has provided
goods and/or services
______________________________________
Company Name Providing Reference
_______________________________________
Signature
____________
Date
FORM E: GENERAL CERTIFICATION FORMS
CERTIFICATION OF CODE OF SILENCE
The Board of Education (Board) has adopted a “Code of Silence” policy (Board Policy CAA (Local)) attached by URL link hereto
and incorporated by reference.
The “Code of Silence" prohibits any communication regarding any RFP, bid, or other competitive solicitation between:
 Any person who seeks an award from the District or its affiliated entities (including, but not limited to, the HISD
Foundation and the HISD Public Facility Corporation), including a potential vendor or vendor's representative, and
 Board members, the Superintendent of Schools, senior staff members, principals, department heads, directors,
managers, or other District representatives who have influence in the evaluation or selection process.
The “Code of Silence” time period shall begin when the RFP is issued and ends upon the execution of the Contract. During the
“Code of Silence,” campaign contributions, gifts, donations, loans, and any other items of value are prohibited between these
parties, including candidates who have filed for election to the Board.
I hereby certify that I have reviewed Board Policy CAA (Local) pertaining to the “Code of Silence,” I and agree and
understand that non-compliance with the “Code of Silence” policy may result in disqualification.
________ Initials of Authorized Representative of Vendor
CERTIFICATION OF COMPLIANCE WITH TEXAS FAMILY CODE PROVISION
As per Section 14.52 of the Texas Family Code, added by S.B. 84, Acts, 73rd Legislature, R.S. (1993), all bidders must
complete and submit with the bid the following: I, the undersigned Vendor, do hereby acknowledge that NO sole proprietor,
partner, majority shareholder of a corporation, or an owner of 10% or more of another business entity is 30 days or more
delinquent in paying child support under a court order or a written repayment agreement. I understand that under this provision, a
sole proprietorship, partnership, corporation or other entity in which a sole proprietor, partner, majority shareholder or a
corporation, or an owner of 10% or more of another entity is 30 days or more delinquent in paying child support under a court
order or a written repayment agreement is NOT eligible to bid or receive a state contract.
________ Initials of Authorized Representative of Vendor
CERTIFICATION OF AUTHORIZATION, PERMITS, AND BUSINESS CERTIFICATES REQUIREMENT
For the duration of the Contract, Vendor must have and maintain current licenses, permits, fees, business certificates and similar
authorizations required by the City of Houston, Harris Country, and the State of Texas to conduct business and provide awarded
goods and/or services to the District. Upon the request of the District, Vendor shall provide copies of all licenses, business
certificates permits and fees as being paid and current that are required to do business by the city, county and State for the type
of business Vendor provides, or seeks to provide, to the District.
Vendor understands and agrees to abide by the Authorization, Permits, and Business Certificates Requirement above.
Vendor certifies that it has all current licenses, certificates, similar authorizations required by the City of Houston, Harris
County, and the State of Texas to conduct business and/or provide awarded goods and/or services to the District.
________ Initials of Authorized Representative of Vendor
CERTIFICATION OF ANTITRUST CERTIFICATION STATEMENT –Texas Government Code Section 2155.005
My initials below affirms under penalty of perjury of the laws of the State of Texas that:
1. I am duly authorized to execute this Proposal/Contract on my own behalf or on behalf of the company, corporation, firm,
partnership or individual (Vendor) listed below;
2. In connection with this proposal, neither I nor any representative of Vendor have 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 Vendor have violated any federal antitrust law; and
4. Neither I nor any representative of Vendor have directly or indirectly communicated any of the contents of this proposal to
a competitor of Vendor or any other company, corporation, firm, partnership or individual engaged in the same line of
business as Vendor.
________ Initials of Authorized Representative of Vendor
CERTIFICATION REGARDING HAZARD ANALYSIS AND CRITICAL CONTROL POINTS (HACCP)
All products purchased by HISD must be manufactured in compliance with HACCP regulations. Vendor certifies that: all
products on this proposal are processed and packaged in a HACCP compliant plant. Vendor agrees Vendor further understands
that HISD requires processors to maintain records and monitoring logs pertaining to HACCP compliance, at a minimum, in the
following Key Areas of HACCP compliance:







Hazard Analysis
Critical Control Points established and limits set
Planned procedures in place to correct processes
when deviation may occur
Detailed and accurate record keeping
Verification procedures
Equipment installation and maintenance
Master cleaning and sanitation schedule







Orientation for all employees
Ongoing training on food safety and HACCP procedures
Separation of food and chemical products
Refrigerated dock receiving and loading
Master cleaning and sanitation schedule
Time/Temperature monitoring
Pest Control
Vendor further understands and agrees that documentation and monitoring logs must be verified by an acceptable third party
auditing firm or government agency and provided to HISD upon request. Vendor also understands and agrees that if a processor
loses inspection/processing rights or has a recall involving product sold to HISD, Vendor must notify HISD within 24-48 hours.
________ Initials of Authorized Representative of Vendor
CERTIFICATION OF VENDOR (AND IF APPLICABLE, SUBCONTRACTOR)
NATIONWIDE CRIMINAL BACKGROUND CHECKS
Pursuant to sections 22.085 and 22.0834 of the Texas Education Code Sections 22.085 and 22.0834 and HISD Policy CJA (Legal),
Vendor hereby certifies that all of Vendor’s employees, subcontractors and volunteers (including those hired before January 1,
2008) who have, or will have, continuing duties related to the contracted services, and who have, or will have, direct contact with
students, have passed a national criminal history background record information review as required by those sections and by HISD
Policy CJA (Legal). Vendor understands that if an employee subcontractor, or volunteer has a Disqualifying Criminal
History, the District may elect not to enter into this Contract or may elect to cancel the Contract.
“Disqualifying Criminal History” means: (1) a conviction or other criminal history information designated by HISD; (2) a felony or
misdemeanor offense that would prevent a person from being employed under Texas Education Code § 22.085(a), that is: if at the time
of the offense, the victim was under 18 or was enrolled in a public school: (a) a felony offense under Title 5, Texas Penal Code; (b) an
offense on conviction for which a defendant is required to register as a sex offender under Chapter 62, Texas Code of Criminal
Procedure; or (c) an offense under federal law or the laws of another state that is equivalent to (a) or (b).
Vendor further certifies that:
(1) Vendor will immediately remove an employee, subcontractor, or volunteer from contract duties and notify HISD in writing
within 3 business days if:
a. Vendor receives information that an employee, subcontractor, or volunteer has a reported criminal history, or
b. HISD objects to the assignment of an employee, subcontractor, or volunteer on the basis of the individual(s) criminal
history review information (CHRI).
(2) Upon request, Vendor will provide HISD with the name and any other requested information of an employee, subcontractor,
or volunteer so that HISD may obtain the CHRI on the individual(s).
________ Initials of Authorized Representative of Vendor
CERTIFICATION OF FELONY CONVICTION NOTIFICATION
Pursuant to section 44.034 of the Texas Education Code, a person or business entity entering into a contract and/or agreement
with HISD must give advance notice to HISD if the person or an owner or operator of the business entity has been convicted of a
felony. The disclosure should include a general description of the conduction resulting in the conviction of a felony. HISD may
terminate a contract with a person of business entity if HISD determines that the person or the business entity failed to give notice
as required by section 44.034 or misrepresented the conduct resulting in the conviction. In such a case, HISD will 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 --Please check the following as applicable:
☐ Vendor is a publicly held corporation; therefore the above reporting requirement does not apply.
☐ Vendor is not owned nor operated by anyone who has been convicted of a felony.
☐ Vendor is operated or owned by the following individual(s) who has/have been convicted of a felony:
Name of Individual(s): ___________________________________________________________________________
Detail of conviction(s), attach additional pages if necessary: ______________________________________________
_____________________________________________________________________________________________
___________________________________________________________________________________________
________ Initials of Authorized Representative of Vendor
CERTIFICATION OF INSURANCE REQUIREMENT
I, the undersigned Vendor, do hereby certify that I shall maintain all insurance policies required by and in accordance with Section
5.27 of this RFP. I further understand and agree that I must make the certificates of insurance and insurance policies available to
HISD upon request.
________ Initials of Authorized Representative of Vendor
CERTIFICATION OF NON-COLLUSION STATEMENT
I, the undersigned Vendor, do hereby certify that:
a)
b)
c)
d)
e)
f)
g)
h)
i)
j)
All statements of fact in such proposal are true.
Such Proposal was not made in the interest of or on behalf of any undisclosed person, partnership, company, association,
organization or corporation.
Such Proposal is genuine and not collusive or sham.
Vendor has not, directly or indirectly by agreement, communication or conference with anyone, attempted to induce action
prejudicial to the interest of the District or of any other bidder or anyone else interested in the proposed procurement.
Vendor did not, directly or indirectly, collude, conspire, connive or agree with anyone else that said bidder or anyone else
would submit a false or sham bid or proposal, or that anyone should refrain from bidding or withdraw his bid or proposal.
Vendor did not, in any manner, directly or indirectly seek by agreement, communication or conference with anyone to
raise or fix the bid or proposal price of said bidder or of anyone else, or to raise or fix any overhead, profit or cost element
of his bid or proposal price, or that of anyone else.
Vendor did not, directly or indirectly, submit his bid or proposal price or any breakdown thereof, or the contents thereof,
or divulge information on data relative thereto, to any corporation, partnership, company, association, organization, bid
depository, or to any member or agent thereof, or to any individual or group of individuals, except to the District, or to any
person or persons who have a partnership or other financial interest with said Proposer in his business.
Vendor did not provide, directly or indirectly to any officer or employee of the District any gratuity, entertainment, meals,
or anything of value, whatsoever, which could be construed as intending to invoke any form of reciprocation or favorable
treatment.
No officer or principal of the undersigned Vendor is related to any officer or employee of the District by blood or marriage
within the third degree or is employed, either full or part time, by the District either currently or within the last two (2) years.
No officer or principal of the undersigned Vendor nor any subcontractor to be engaged by the principal has been convicted
k)
by a court of competent jurisdiction of any charge of fraud, bribery, collusion, conspiracy or any other act in violation of
any state or federal anti-trust law in connection with the bidding, award of, or performance of any public work contract
and/or agreement with any public entity.
I have answered the questions regarding non-collusion truthfully and to the best of my knowledge.
________ Initials of Authorized Representative of Vendor
VENDOR AGREES TO COMPLY WITH ALL APPLICABLE FEDERAL, STATE, AND LOCAL LAWS, RULES, REGULATIONS,
AND ORDINANCES. IT IS FURTHER ACKNOWLEDGED THAT VENDOR CERTIFIES COMPLIANCE WITH ALL PROVISIONS,
LAWS, ACTS, REGULATIONS, ETC. AS SPECIFICALLY NOTED ABOVE.
Vendor’s Name: _______________________________________________________________________________________
Address, City, State, and Zip Code: ________________________________________________________________________
Phone Number: ____________________________________
Fax Number: ____________________________________
Printed Name and Title of Authorized Representative: __________________________________________________________
Email Address: ________________________________________________________________________________________
Signature of Authorized Representative: _____________________________________________________________________
Date: ___________________________
FORM F:
PRICE AND PRICING SCHEDULE
Please refer to Separate Attachment F- Pricing Schedule and place in Tab 7
FORM G: EDGAR CERTIFICATIONS
The following certifications and provisions are required and apply when HISD expends federal funds for any contract resulting from
this procurement process. Accordingly, the parties agree that the following terms and conditions apply to the Contract
between the District and [name of vendor] (“Vendor”) in all situations where Vendor has been paid or will be paid with
federal funds:
REQUIRED CONTRACT PROVISIONS FOR NON-FEDERAL ENTITY CONTRACTS UNDER FEDERAL AWARDS
APPENDIX II TO 2 CFR PART 200
(A) Contracts for more than the simplified acquisition threshold currently set at $150,000, which is the inflation adjusted
amount determined by the Civilian Agency Acquisition Council and the Defense Acquisition Regulations Council
(Councils) as authorized by 41 U.S.C. 1908, must address administrative, contractual, or legal remedies in instances
where contractors violate or breach contract terms, and provide for such sanctions and penalties as appropriate.
Pursuant to Federal Rule (A) above, when HISD expends federal funds, HISD reserves all rights and privileges under
the applicable laws and regulations with respect to this procurement in the event of breach of contract by either party.
Does Vendor agree? YES ________ Initials of Authorized Representative of Vendor
(B) Termination for cause and for convenience by the grantee or subgrantee including the manner by which it will be
effected and the basis for settlement. (All contracts in excess of $10,000)
Pursuant to Federal Rule (B) above, when HISD expends federal funds, HISD reserves the right to immediately terminate
any agreement in excess of $10,000 resulting from this procurement process in the event of a breach or default of the
agreement by Vendor in the event Vendor fails to: (1) meet schedules, deadlines, and/or delivery dates within the time
specified in the procurement solicitation, contract, and/or a purchase order; (2) make any payments owed; or (3)
otherwise perform in accordance with the contract and/or the procurement solicitation. HISD also reserves the right to
terminate the contract immediately, with written notice to vendor, for convenience, if HISD believes, in its sole discretion
that it is in the best interest of HISD to do so. Vendor will be compensated for work performed and accepted and goods
accepted by HISD as of the termination date if the contract is terminated for convenience of HISD. Any award under this
procurement process is not exclusive and HISD reserves the right to purchase goods and services from other vendors
when it is in HISD’s best interest.
Does Vendor agree? YES ________ Initials of Authorized Representative of Vendor
(C) Equal Employment Opportunity. Except as otherwise provided under 41 CFR Part 60, all contracts that meet the
definition of “federally assisted construction contract” in 41 CFR Part 60-1.3 must include the equal opportunity clause
provided under 41 CFR 60-1.4(b), in accordance with Executive Order 11246, “Equal Employment Opportunity” (30 FR
12319, 12935, 3 CFR Part, 1964-1965 Comp., p. 339), as amended by Executive Order 11375, “Amending Executive Order
11246 Relating to Equal Employment Opportunity,” and implementing regulations at 41 CFR part 60, “Office of Federal
Contract Compliance Programs, Equal Employment Opportunity, Department of Labor.”
Pursuant to Federal Rule (C) above, when HISD expends federal funds on any federally assisted construction contract,
the equal opportunity clause is incorporated by reference herein.
Does Vendor agree to abide by the above? YES ________ Initials of Authorized Representative of Vendor
(D) Davis-Bacon Act, as amended (40 U.S.C. 3141-3148). When required by Federal program legislation, all prime
construction contracts in excess of $2,000 awarded by non-Federal entities must include a provision for compliance with
the Davis-Bacon Act (40 U.S.C. 3141-3144, and 3146-3148) as supplemented by Department of Labor regulations (29 CFR
Part 5, “Labor Standards Provisions Applicable to Contracts Covering Federally Financed and Assisted Construction”).
In accordance with the statute, contractors must be required to pay wages to laborers and mechanics at a rate not less
than the prevailing wages specified in a wage determination made by the Secretary of Labor. In addition, contractors
must be required to pay wages not less than once a week. The non-Federal entity must place a copy of the current
prevailing wage determination issued by the Department of Labor in each solicitation. The decision to award a contract
or subcontract must be conditioned upon the acceptance of the wage determination. The non-Federal entity must report
all suspected or reported violations to the Federal awarding agency. The contracts must also include a provision for
compliance with the Copeland “Anti-Kickback” Act (40 U.S.C. 3145), as supplemented by Department of Labor regulations
(29 CFR Part 3, “Contractors and Subcontractors on Public Building or Public Work Financed in Whole or in Part by Loans
or Grants from the United States”). The Act provides that each contractor or subrecipient must be prohibited from
inducing, by any means, any person employed in the construction, completion, or repair of public work, to give up any
part of the compensation to which he or she is otherwise entitled. The non-Federal entity must report all suspected or
reported violations to the Federal awarding agency.
Pursuant to Federal Rule (D) above, when HISD expends federal funds during the term of an award for all contracts and
subgrants for construction or repair, Vendor will be in compliance with all applicable Davis-Bacon Act provisions.
Does Vendor agree? YES ________ Initials of Authorized Representative of Vendor
(E) Contract Work Hours and Safety Standards Act (40 U.S.C. 3701-3708). Where applicable, all contracts awarded by the
non-Federal entity in excess of $100,000 that involve the employment of mechanics or laborers must include a provision
for compliance with 40 U.S.C. 3702 and 3704, as supplemented by Department of Labor regulations (29 CFR Part 5). Under
40 U.S.C. 3702 of the Act, each contractor must be required to compute the wages of every mechanic and laborer on the
basis of a standard work week of 40 hours. Work in excess of the standard work week is permissible provided that the
worker is compensated at a rate of not less than one and a half times the basic rate of pay for all hours worked in excess
of 40 hours in the work week. The requirements of 40 U.S.C. 3704 are applicable to construction work and provide that
no laborer or mechanic must be required to work in surroundings or under working conditions which are unsanitary,
hazardous or dangerous. These requirements do not apply to the purchases of supplies or materials or articles ordinarily
available on the open market, or contracts for transportation or transmission of intelligence.
Pursuant to Federal Rule (E) above, when HISD expends federal funds, Vendor certifies that Vendor will be in compliance
with all applicable provisions of the Contract Work Hours and Safety Standards Act during the term of an award for all
contracts by HISD resulting from this procurement process.
Does Vendor agree? YES ________ Initials of Authorized Representative of Vendor
(F) Rights to Inventions Made Under a Contract or Agreement. If the Federal award meets the definition of “funding
agreement” under 37 CFR §401.2 (a) and the recipient or subrecipient wishes to enter into a contract with a small business
firm or nonprofit organization regarding the substitution of parties, assignment or performance of experimental,
developmental, or research work under that “funding agreement,” the recipient or subrecipient must comply with the
requirements of 37 CFR Part 401, “Rights to Inventions Made by Nonprofit Organizations and Small Business Firms Under
Government Grants, Contracts and Cooperative Agreements,” and any implementing regulations issued by the awarding
agency.
Pursuant to Federal Rule (F) above, when federal funds are expended by HISD, Vendor certifies that during the term of
an award for all contracts by HISD resulting from this procurement process, Vendor agrees to comply with all applicable
requirements as referenced in Federal Rule (F) above.
Does Vendor agree? YES ________ Initials of Authorized Representative of Vendor
(G) Clean Air Act (42 U.S.C. 7401-7671q.) and the Federal Water Pollution Control Act (33 U.S.C. 1251-1387), as amended—
Contracts and subgrants of amounts in excess of $150,000 must contain a provision that requires the non-Federal award
to agree to comply with all applicable standards, orders or regulations issued pursuant to the Clean Air Act (42 U.S.C.
7401-7671q) and the Federal Water Pollution Control Act as amended (33 U.S.C. 1251- 1387). Violations must be reported
to the Federal awarding agency and the Regional Office of the Environmental Protection Agency (EPA).
Pursuant to Federal Rule (G) above, when federal funds are expended by HISD, Vendor certifies that during the term of
an award for all contracts by HISD resulting from this procurement process, Vendor agrees to comply with all applicable
requirements as referenced in Federal Rule (G) above.
Does Vendor agree? YES ________ Initials of Authorized Representative of Vendor
(H) Debarment and Suspension (Executive Orders 12549 and 12689)—A contract award (see 2 CFR 180.220) must not be
made to parties listed on the government wide exclusions in the System for Award Management (SAM), in accordance
with the OMB guidelines at 2 CFR 180 that implement Executive Orders 12549 (3 CFR part 1986 Comp., p. 189) and 12689
(3 CFR part 1989 Comp., p. 235), “Debarment and Suspension.” SAM Exclusions contains the names of parties debarred,
suspended, or otherwise excluded by agencies, as well as parties declared ineligible under statutory or regulatory
authority other than Executive Order 12549.
Pursuant to Federal Rule (H) above, when federal funds are expended by HISD, Vendor certifies that during the term of
an award for all contracts by HISD resulting from this procurement process, Vendor certifies that neither it nor its
principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from
participation by any federal department or agency.
Does Vendor agree? YES ________ Initials of Authorized Representative of Vendor
(I) Byrd Anti-Lobbying Amendment (31 U.S.C. 1352)—Contractors that apply or bid for an award exceeding $100,000 must
file the required certification. Each tier certifies to the tier above that it will not and has not used Federal appropriated
funds to pay any person or organization for influencing or attempting to influence an officer or employee of any agency,
a member of Congress, officer or employee of Congress, or an employee of a member of Congress in connection with
obtaining any Federal contract, grant or any other award covered by 31 U.S.C. 1352. Each tier must also disclose any
lobbying with non-Federal funds that takes place in connection with obtaining any Federal award. Such disclosures are
forwarded from tier to tier up to the non-Federal award.
Pursuant to Federal Rule (I) above, when federal funds are expended by HISD, Vendor certifies that during the term and
after the awarded term of an award for all contracts by HISD resulting from this procurement process, the vendor certifies
that it is in compliance with all applicable provisions of the Byrd Anti-Lobbying Amendment (31 U.S.C. 1352). The
undersigned further certifies that:
(1) No Federal appropriated funds have been paid or will be paid for on behalf of the undersigned, 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 the awarding of
a Federal contract, the making of a Federal grant, the making of a Federal loan, the entering into a cooperative
agreement, and the extension, continuation, renewal, amendment, or modification of a 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 grant or cooperative
agreement, the undersigned shall complete and submit Standard Form-LLL, “Disclosure Form to Report
Lobbying”, in accordance with its instructions.
(3) The undersigned shall require that the language of this certification be included in the award documents for all
covered sub-awards exceeding $100,000 in Federal funds at all appropriate tiers and that all subrecipients
shall certify and disclose accordingly.
Does Vendor agree? YES ________ Initials of Authorized Representative of Vendor
RECORD RETENTION REQUIREMENTS FOR CONTRACTS INVOLVING FEDERAL FUNDS
When federal funds are expended by HISD for any contract resulting from this procurement process, Vendor certifies that it will
comply with the record retention requirements detailed in 2 CFR § 200.333. Vendor further certifies that it will retain all records as
required by 2 CFR § 200.333 for a period of three years after grantees or subgrantees submit final expenditure reports or quarterly
or annual financial reports, as applicable, and all other pending matters are closed.
Does Vendor agree? YES ________ Initials of Authorized Representative of Vendor
CERTIFICATION OF COMPLIANCE WITH THE ENERGY POLICY AND CONSERVATION ACT
When HISD expends federal funds for any contract resulting from this procurement process, Vendor certifies that it will comply
with the mandatory standards and policies relating to energy efficiency which are contained in the state energy conservation plan
issued in compliance with the Energy Policy and Conservation Act (42 U.S.C. 6321 et seq.; 49 C.F.R. Part 18).
Does Vendor agree? YES ________ Initials of Authorized Representative of Vendor
CERTIFICATION OF EQUAL EMPLOYMENT STATEMENT
It is the policy of HISD not to discriminate on the basis of race, color, national origin, gender, limited English proficiency or
handicapping conditions in its programs. Vendor agrees not to discriminate against any employee or applicant for employment to
be employed in the performance of this Contract, with respect to hire, tenure, terms, conditions and privileges of employment, or
a matter directly or indirectly related to employment, because of age (except where based on a bona fide occupational qualification),
sex (except where based on a bona fide occupational qualification) or race, color, religion, national origin, or ancestry. Vendor
further agrees that every subcontract entered into for the performance of this Contract shall contain a provision requiring nondiscrimination in employment herein specified, binding upon each subcontractor. Breach of this covenant may be regarded as a
material breach of the Contract.
Does Vendor agree? YES ________ Initials of Authorized Representative of Vendor
CERTIFICATION OF COMPLIANCE WITH BUY AMERICA PROVISIONS
HISD has a preference for domestic end products for supplies acquired for use in the United States when spending federal funds
(purchases that are made with non-federal funds or grants are excluded from the Buy America Act). Vendor certifies that it is in
compliance with all applicable provisions of the Buy America Act.
Does Vendor agree? YES ________ Initials of Authorized Representative of Vendor
CERTIFICATION OF ACCESS TO RECORDS – 2 C.F.R. § 200.336
Vendor agrees that the District’s Inspector General or any of their duly authorized representatives shall have access to any books,
documents, papers and records of Vendor that are directly pertinent to Vendor’s discharge of its obligations under the Contract for
the purpose of making audits, examinations, excerpts, and transcriptions. The right also includes timely and reasonable access to
Vendor’s personnel for the purpose of interview and discussion relating to such documents.
Does Vendor agree? YES ________ Initials of Authorized Representative of Vendor
CERTIFICATION OF APPLICABILITY TO SUBCONTRACTRS
Vendor agrees that all contracts it awards pursuant to the Contract shall be bound by the foregoing terms and conditions.
Does Vendor agree? YES ________ Initials of Authorized Representative of Vendor
VENDOR AGREES TO COMPLY WITH ALL APPLICABLE FEDERAL, STATE, AND LOCAL LAWS, RULES, REGULATIONS,
AND ORDINANCES. IT IS FURTHER ACKNOWLEDGED THAT VENDOR CERTIFIES COMPLIANCE WITH ALL PROVISIONS,
LAWS, ACTS, REGULATIONS, ETC. AS SPECIFICALLY NOTED ABOVE.
Vendor’s Name: _______________________________________________________________________________________
Address, City, State, and Zip Code: ________________________________________________________________________
Phone Number: ____________________________________
Fax Number: ____________________________________
Printed Name and Title of Authorized Representative: __________________________________________________________
Email Address: ________________________________________________________________________________________
Signature of Authorized Representative: _____________________________________________________________________
Date: ___________________________
FORM H: EXCEPTION FORM
All deviations and exceptions to the RFP must be expressly stated in this Exception Form (additional pages to this form
may be added if necessary). In the absence of any entry on this Exception Form, Vendor assures HISD of its full agreement and
compliance with all specifications, terms and conditions, requirements and obligations of the RFP. All exceptions must detail the
section number, paragraph number, page number, and the specific language excepted.
YOU MUST SIGN AND SUBMIT THIS FORM WITH YOUR PROPOSAL REGARDLESS OF WHETHER THERE ARE
EXCEPTIONS LISTED OR NOT.
Vendor Name
Officer’s Signature
Printed Name
Date
FORM I: CONFLICT OF INTEREST CERTIFICATION AND
CONFLICT OF INTEREST QUESTIONNAIRE (CIQ) INSTRUCTIONS
I.
CONFLICT OF INTEREST CERTIFICATION
The Board of Education (Board) has adopted a “Conflict of Interest Disclosures” policy (Board Policy BBFA (Local)) attached by
URL link hereto and incorporated by reference.
HISD is required to comply with Texas Local Government Code Chapter 176, Disclosure of Certain Relationships with Local
Government Officers as well as the conflict of interest standards set forth in EDGAR, 2 C.F.R. § 200.318 when HISD expends
federal funds. No employee, officer, or agent may participate in the selection, award, or administration of a contract if he or she
has a real or apparent conflict of interest. HISD local government officers must disclose conflicts of interest by completing Form
CIS, Local Government Officer Conflicts Disclosure Statement.
I hereby certify that I have read Board Policy BBFA (Local) pertaining to “Conflict of Interest Disclosures,” and I agree
and understand that the failure of a Board member to disclose a conflict of interest may result in the debarment of a
Vendor for 24 months.
________ Initials of Authorized Representative of Vendor
II.
CONFLICT OF INTEREST QUESTIONNAIRE (CIQ) INSTRUCTIONS
HISD is required to comply with Texas Local Government Code Chapter 176, Disclosure of Certain Relationships with Local
Government Officers. H.B. 23 significantly changed the laws relating to Conflict of Interest Disclosures as well as the corresponding
forms and required disclosures. As of September 1, 2015, Vendor must sign and complete the new Conflict of Interest
Questionnaire (CIQ) and submit the CIQ with its proposal.
In accordance with Chapter 176 of the Texas Local Government Code, any vendor who does business with HISD or who seeks to
do business with HISD must fill out the new Conflict of Interest Questionnaire (CIQ) whether or not a conflict of interest exists. A
conflict of interest exists in the following situations:
1)
2)
3)
If the vendor has an employment or other business relationship with a local government officer of HISD or a family
member of the officer, as described by section 176.003(a)(2)(A) of the Texas Local Government Code; or
If the vendor given a local government officer of HISD, or a family member of the officer, one or more gifts with the
aggregate value of $100, excluding any gift accepted by the officer or a family member of the officer if the gift is: (a) a
political contribution as defined by Title 15 of the Election Code; or (b) a gift of food accepted as a guest; or
If the vendor a family relationship with a local government officer of HISD.
“Vendor” means a person who enters or seeks to enter into a contract with a local governmental entity. The term includes an
agent of a vendor. The term includes an officer or employee of a state agency when that individual is acting in a private capacity
to enter into a contract. The term does not include a state agency except for Texas Correctional Industries. Texas Local
Government Code 176.001(7).
“Business relationship” means a connection between two or more parties based on commercial activity of one of the parties.
The term does not include a connection based on: (A) a transaction that is subject to rate or fee regulation by a federal, state, or
local governmental entity or an agency of a federal, state, or local governmental entity; (B) a transaction conducted at a price and
subject to terms available to the public; or (C) a purchase or lease of goods or services from a person that is chartered by a state
or federal agency and that is subject to regular examination by, and reporting to, that agency. Texas Local Government Code
176.001(3).
“Local government officer” means: (A) a member of the governing body of a local governmental entity; (B) a director,
superintendent, administrator, president, or other person designated as the executive officer of a local governmental entity; or
(C) an agent of a local governmental entity who exercises discretion in the planning, recommending, selecting, or contracting of
a vendor. Texas Local Government Code 176.001(4).
“Family relationship” means a relationship between a person and another person within the third degree by consanguinity or the
second degree by affinity, as those terms are defined by Subchapter B, Chapter 573, Government Code. Texas Local Government
Code 176.001(2-a).
VENDOR MUST SIGN AND SUBMIT FORM CIQ EVEN IF NO CONFLICT EXISTS.
If no conflict exists, Vendor must fill out Box 1 and write N/A in Box 3.
I hereby certify that I have read Form I, Conflict of Interest Questionnaire (CIQ) Instructions, and I agree and understand
that the failure to disclose a conflict of interest and/or the failure to sign and submit Form CIQ, even if no conflict exists,
with this proposal may result in disqualification.
Name of Authorized Representative: ________________________________________________________________________
Signature of Authorized Representative: _____________________________________________________________________
Date: ___________________________
FORM CIQ
CONFLICT OF INTEREST QUESTIONNAIRE
For vendor doing business with local government entity
OFFICE USE ONLY
This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session.
This questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a
vendor who has a business relationship as defined by Section 176.001(1-a) with a local governmental
entity and the vendor meets requirements under Section 176.006(a).
Date Received
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 vendor becomes aware of facts that require the
statement to be filed. See Section 176.006(a-1), Local Government Code.
A vendor commits an offense if the vendor knowingly violates Section 176.006, Local
Government Code. An offense under this section is a misdemeanor.
1
Name of vendor 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 on which you became aware that the originally filed questionnaire
was incomplete or inaccurate.)
3
Name of local government officer about whom the information in this section is being dislcosed.
Name of Officer
This section (item 3 including subparts A, B, C & D) must be completed for each officer with whom the vendor has an employment or other
business relationship as defined by Section 176.001(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 vendor?
Yes
No
B. Is the vendor receiving or likely to receive taxable income, other than investment income, from or at the direction of the local
government office 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 interest of one percent or more?
Yes
No
D. Describe each employment or business and family relationship with the local government officer named in this section.
4
Signature of vendor doing business with the governmental entity
Date
Adopted 08/07/2015
FORM J: HISD CERTIFICATE OF INTERESTED PARTIES – FORM 1295
Certificate of Interested Parties (Form 1295 – must be filled out electronically with the Texas Ethics Commission’s
online filing application, printed out, signed, notarized, and attached to vendor’s response to this solicitation.
Houston ISD (“HISD”) is required to comply with House Bill 1295, which amended the Texas Government Code by adding
Section 2252.908, Disclosure of Interested Parties. Section 2252.908 prohibits HISD from entering into a contract resulting
from this RFP with a business entity unless the business entity submits a Disclosure of Interested Parties (Form 1295) to HISD
at the time business entity submits the signed contract. The Texas Ethics Commission has adopted rules requiring the business
entity to file Form 1295 electronically with the Texas Ethics Commission.
“Interested Party” means a person:
a) who has a controlling interest in a business entity with whom HISD contracts; or
b) who actively participates in facilitating the contract or negotiating the terms of the contract, including a broker,
intermediary, adviser, or attorney for the business entity.
“Business Entity” means an entity recognized by law through which business is conducted, including a sole proprietorship,
partnership, or corporation.
As a “business entity,” all vendors must electronically complete, print, sign, notarize, and submit Form 1295 with their
proposals even if no interested parties exist.
Proposers must file Form 1295 electronically with the Texas Ethics Commission using the online filing application, which can
be found at https://www.ethics.state.tx.us/whatsnew/elf_info_form1295.htm. Proposers must use the filing application on the
Texas Ethics Commission’s website to enter the required information on Form 1295. Proposers must print a copy of the
completed form, which will include a certification of filing containing a unique certification number. The Form 1295 must be
signed by an authorized agent of the business entity, and the form must be notarized.
The completed Form 1295 with the certification of filing must be filed with HISD by attaching the completed form to the
vendor’s solicitation response.
HISD must acknowledge the receipt of the filed Form 1295 by notifying the Texas Ethics Commission of the receipt of the
filed Form 1295 no later than the 30th day after the date the contract binds all parties to the contract. After HISD acknowledges
the Form 1295, the Texas Ethics Commission will post the completed Form 1295 to its website with seven business days after
receiving notice from HISD. The acknowledgement of your 1295 form does not guarantee that you will be selected as an
approved vendor. An evaluation committee will select the vendor(s) for the project and the Board of Education will approve
it during the next available board meeting. An award or regret letter will be sent once the selection and approval process is
complete. In the event that your proposal is not selected, we will request you to withdraw your 1295 form from the Texas
Ethics Commission website.
FORM L: CERTIFICATE OF INSURANCE (ACORD FORM)
Please include the Certificate of Insurance (Acord Form) or a Letter from its insurance provider stating that
proposer can provide the levels of insurance required in this RFP – section