Chatham Parkway Improvements

ATTACHMENT A
DRUG - FREE WORKPLACE CERTIFICATION
THE UNDERSIGNED CERTIFIES THAT THE PROVISIONS OF CODE SECTIONS 50-24-1
THROUGH 50-24-6 OF THE OFFICIAL CODE TO GEORGIA ANNOTATED, RELATED
TO THE **DRUG-FREE WORKPLACE**, HAVE BEEN COMPLIED WITH IN FULL. THE
UNDERSIGNED FURTHER CERTIFIES THAT:
1. A Drug-Free Workplace will be provided for the employees during the performance of
the contract; and
2. Each sub-contractor under the direction of the Contractor shall secure the following
written certification:
___________________________________________________________(CONTRACTOR)
certifies to the City of Garden City that a Drug-Free Workplace will be provided for the
employees during the performance of this contract known as procurement CHATHAM
PARKWAY IMPROVEMENTS (PROJECT) pursuant to paragraph (7) of subsection (B) of
Code Section 50-24-3. Also, the undersigned further certifies that he/she will not engage in the
unlawful manufacture, sale, distribution, possession, or use of a controlled substance or
marijuana during the performance of the contract.
_________________________________________ ______________________
CONTRACTOR DATE
_________________________________________ ______________________
NOTARY DATE

ATTACHMENT B
CONTRACTOR AFFIDAVIT under O.C.G.A. 13-10-91(B)(1)
By executing this affidavit, the undersigned contractor verifies its compliance with O.C.G.A.
13-10-91, stating affirmatively that the individual, firm or corporation which is engaged in the
physical performance of services on behalf of The City of Garden City has registered with, is
authorized to use and uses the federal work authorization program commonly known as E-
Verify, or any subsequent replacement program, in accordance with the applicable provisions
and deadlines established in O.C.G.A. 13-10-91. Furthermore, the undersigned contractor will
continue to use the federal work authorization program throughout the contract period and the
undersigned contractor will contract for the physical performance of services in satisfaction of
such contract only when subcontractors who present an affidavit to the contractor with the
information required by O.C.G.A. 13-10-91(b). Contractor hereby attests that its federal work
authorization user identification number and date of authorization are as follows:
___________________________________
Federal Work Authorization User Identification Number
__________________________________
Date of Authorization
___________________________________
Name of Contractor
___________________________________
Name of Project
I hereby declare under penalty of perjury that the foregoing is true and correct.
Executed on________, _______, 2021 in ___________________(city), __________(state)
_____________________________________
Signature of Authorized Officer or Agent
_____________________________________
Printed Name and Title of Authorized Officer or Agent
State of ___________________________County of _________________________
Subscribed and sworn to before me on this _____________ day of _________________
2021 by ______________________________________ representing him/herself to be
______________________ of the company named herein.
________________________________________________________________________
Notary Public
My Commission Expires: Resident State
________________________ _________________

ATTACHMENT C
SUBCONTRACTOR AFFIDAVIT under O.C.G.A. 13-10-91(B)(3)
By executing this affidavit, the undersigned subcontractor verifies its compliance with O.C.G.A. 13-10-
91, stating affirmatively that the individual, firm or corporation which is engaged in the physical
performance of services on behalf of the City of Garden City has registered with, is authorized to use and
uses the federal work authorization program commonly known as E-Verify, or any subsequent
replacement program, in accordance with the applicable provisions and deadlines established in O.C.G.A.
13-10-91. Furthermore, the undersigned subcontractor will continue to use the federal work
authorization program throughout the contract period and the undersigned contractor will contract for the
physical performance of services in satisfaction of such contract only when subcontractors who present an
affidavit to the contractor with the information required by O.C.G.A. 13-10-91(b). Additionally, the
undersigned subcontractor will forward notice of the receipt of an affidavit from a sub-subcontractor to
the contractor within five (5) business days of receipt. If the undersigned subcontractor receives notice of
receipt of an affidavit from any sub-subcontractor that has contracted with a sub-subcontractor to forward,
withing five (5) business days of receipt, a copy of such notice to the contractor. Subcontractor hereby
attests that its federal work authorization user identification number and date of authorization are as
follows:
___________________________________
Federal Work Authorization User Identification Number
__________________________________
Date of Authorization
___________________________________
Name of Subcontractor
___________________________________
Name of Project
I hereby declare under penalty of perjury that the foregoing is true and correct.
Executed on________, _______, 2021 in ___________________(city), __________(state)
_____________________________________
Signature of Authorized Officer or Agent
_____________________________________
Printed Name and Title of Authorized Officer or Agent
State of ___________________________County of _________________________
Subscribed and sworn to before me on this _____________ day of _________________
2021 by ________________________ representing him/herself to be
______________________ of the company named herein.
________________________________________________________________________
Notary Public
My Commission Expires: Resident State

________________________ _________________
ATTACHMENT D
SAVE AFFIDAVIT IN ACCORDANCE WITH O.C.G.A 50-36-1(e)(2)
By executing this affidavit under oath, as an applicant for a contract with the City of Garden
City, or other public benefit as provided by O.C.G.A. 50-36-1, and determined by the Attorney
General of Georgia in accordance therewith, I state the following with respect to my application
for a public benefit from the City of Garden City:
For: ___________________________________________________________________ .
[Name of natural person applying on behalf of individual, business, corporation, partnership, or
other private entity]
1) _______I am a United States Citizen OR
2) _______I am a legal permanent resident 18 years of age or older or
3) _______I am an otherwise qualified alien or non-immigrant under the Federal Immigration
and Nationality Act 18 years of age or older and lawfully present in the United States. All non-
citizens must provide their Alien Registration Number below.
Alien Registration number for non-citizens _____________________________________
The undersigned applicant also hereby verifies that he or she has provided at least one secure and
verifiable document as required by O.C.G.A. 50-36-1(e)(1) with this Affidavit. The secure and
verifiable document provided with this affidavit is:
______________________________________________________________
In making the above representation under oath, I understand that any person who knowingly and
willfully makes a false, fictitious, or fraudulent statement or representation in an affidavit shall
be guilty of a violation of O.C.G.A. 16-10-20, and face criminal penalties as allowed by such
criminal statute
Signature of Applicant:_____________________________________________________
Date: ___________________
Printed Name: ___________________________________________
Sworn to and subscribed before me This ____ day of _______________, 2022
Notary Public My commission expires:

ATTACHMENT E
REFERENCE FORM
For bidders to be deemed responsive, each must provide information on the most recent three
(3) projects with similar scope of work as well as other information to determine experience and
qualifications as follows.
1) Project Name:_________________________________________________________
Location:_____________________________________________________________
Owner:_______________________________________________________________
Address:______________________________________________________________
City and State:_________________________________________________________
Contact:_______________________________________________________________
Phone & Fax:__________________________________________________________
Engineer of Record:_____________________________________________________
Contact:_______________________________________________________________
Phone & Fax:___________________________________________________________
Email:_________________________________________________________________
2) The awarded bid amount and project start date._____________________________
3) Final cost of project and completion date.___________________________________
4) Number of Change Orders._______________________________________________
5) Contracted project completion in days._____________________________________
6) Project completed on time? Yes________ No________ Days exceeded__________
7) Has contractor ever failed to complete a project?______ If so, provide explanation.
8) Have any projects ever performed by contractor been the subject of a claim or
lawsuit by or against the contractor? _________ If yes, please identify the nature of
such claim or lawsuit, the court in which the case was filed and the details of its
resolution.

CHECKLIST FOR SUBMITTING BID
1) Acknowledgment of any/all addendums.
2) Original surety bond (5% of Bid) along with surety requirements sheets filled out.
3) Bid sheet completely filled out and signed.
4) "List of Subcontractors" sheet filled out with all subcontractors and suppliers.
5) "% to MBE Subcontractors/Suppliers' Sheet" completely filled out showing the %
of project that is projected to go to MBE/WBE Subcontractors/Suppliers.
6) Submit at least 3 references of projects similar in scope to bidded project.
7) Complete and submit all attachments to this Invitation to Bid.
8) Provide a copy of the General Contractor's GDOT Pre-Qualification.
________________________________________________
Name/Title
________________________________________________
Company Name
________________________________________________
Address
________________________________________________
City/State/Zip
________________________________________________
Phone/Fax Numbers
________________________________________________
Email