26-ES-01-WYEMS – Fuel Tank Rental & Fuel Delivery

EXHIBIT A ACKNOWLEDGEMENT AND AGREEMENT TO COMPLY WITH STANDARD
CLAUSES FOR NEW YORK STATE CONTRACTS (APPENDIX A)
I hereby acknowledge that I have read, understand and agree to comply with the terms as outlined in
Appendix A Standard Clauses for New York State Contracts. Failure to comply may result in immediate
termination of this agreement with potential legal recourse by the County.
Signed: Date:
Title:
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EXHIBIT B DRUG FREE WORKPLACE
Whenever two or more Bids which are equal with respect to price, quality and service are received by the
State or by any political subdivisions for the procurement of commodities or contractual services, a Bid
received from a business that certifies that it has implemented a drug-free workplace program shall be
given preference in the award process. Established procedures for processing the Bids will be followed if
none of the tied vendors have a drug free workplace program. In order to have a drug-free workplace
program, a business shall:
1) Publish a statement notifying employees that the unlawful manufacture, distribution, dispensing,
possession or use of a controlled substance is prohibited in the workplace and specifying the
actions that will be taken against employees for violations of such prohibition.
2) Inform employees about the dangers of drug abuse in the workplace,
maintaining a drug free workplace, any available drug counseling, rehabilitation, and employee
assistance programs, and the penalties that may be imposed upon employees for drug abuse
violations.
3) Give each employee engaged in providing the commodities or contractual services that are under
Bid a copy of the statement specified in Subsection (1).
4) In the statement specified in Subsection (1), notify employees, that, as a condition of working of
the commodities or contractual services that are under bid, the employee will abide by the terms
of the statement and will notify the employee of any conviction of, or plea of guilty or nolo
contendere to, any violation of any controlled substance law in the United States or any state or
Wyoming County, for a violation occurring in the workplace no later than five (5) days after such
conviction.
5) Impose a sanction on, or require the satisfactory participation in a drug abuse assistance or
rehabilitation program, if such is available in the employe
so convicted.
6) Make a good faith effort to continue to maintain a drug free workplace through implementation of
this section.
As the person authorized to sign the statement, I certify that this firm complies with the above
requirements.
Print Name: Date:
Signature: Title:
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EXHIBIT C - NON COLLUSIVE BIDDING CERTIFICATE REQUIRED BY
SECTION 139-D OF THE STATE FINANCE LAW
Section 139D, Statement of Non-Collusion in bids to the State:
By submission of this bid, bidder and each person signing on behalf of bidder certifies, and in the case of
joint bid, each party thereto certifies as its own organization, under penalty of perjury, that to the best of
his/her knowledge, and belief:
1) The prices of this bid have been arrived at independently, without collusion, consultation,
communication, or agreement, for the purposes of restricting competition, as to any matter relating
to such prices with any other bidder or with any other competitor;
2) Unless otherwise required by law, the prices which have been quoted in this bid have not been
knowingly disclosed by the Bidder and will not knowingly be disclosed by the Bidder prior to
opening, directly or indirectly, to any other bidder or to any competitor; and
3) No attempt has been made or will be made by the Bidder to induce any other person, partnership
or corporation to submit or not to submit a bid for the purpose of restricting completion.
A Bid shall not be considered for award nor shall any award be made where 1, 2, 3 above have not been
complied with; provided however, that if in any case, the bidder(s) cannot make the foregoing certification,
the bidder shall so state and shall furnish below a signed statement which sets forth in detail the reasons
therefore:
(Affix addendum to this page if space is required for statement.)
Subscribed to me under penalty of perjury under the laws of the State of New York, this
day of , 20 as the act and deed of said corporation of
partnership or sole proprietor.
If Bidders are a Partnership, complete the Following:
Names of Partners or Principals Legal Residence
If Bidders are a corporation, complete the following:
Name Legal Residence
President
Vice President
Secretary
Treasurer
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IdentifyingData:
Potential Contractor:
Address:
Telephone #: Title:
E-Mail Address:
If applicable, Responsible Corporate Officer
Name: Title:
Signature:
Joint or combined bids by companies or firms must be certified by each participant.
Legal name of person or firm Legal name of person or firm
Name Name
Title Title
Address Address
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EXHIBIT D - CONFLICT OF INTEREST DISCLOSURE
Conflict of Interest Disclosure Form
Note: A potential or actual conflict of interest exists when commitments and obligations are likely to be
cially economic),
particularly if those interests or commitments are not disclosed.
This Conflict of Interest Form should indicate whether the nominator(s) has an economic interest in, or
acts as an officer or a director of, any outside entity whose financial interests would reasonably appear to
be affected by the contract. The nominator(s) should also disclose any personal, business, or volunteer
affiliations that may give rise to a real or apparent conflict of interest. Relevant Federally and
organizationally established regulations and guidelines in financial conflicts must be abided by.
Individuals with a conflict of interest should refrain from bidding and/or contracting.
Date:
Name:
Position:
Please describe below any relationships, transactions, positions you hold (volunteer or otherwise), or
circumstances that you believe could contribute to a conflict of interest:
I have no conflict of interest to report.
I have the following conflict of interest to report (please specify other nonprofit and for-profit
boards you (and your spouse) sit on, any for-profit businesses for which you or an immediate family
member are an officer or director, or a majority shareholder, and the name of your employer and any
businesses you or a family member own):
1.
2.
3.
I hereby certify that the information set forth above is true and complete to the best of my knowledge.
Signature:
Company:
Date:
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