RFQ Q004157 On-Call Asphalt Patching and Pavement Restoration Services

This Informal Request for Proposals, signed by an individual who has authority to bind the partnership or corporation, shall
be considered an offer on the part of the offeror and shall be deemed accepted upon approval by the City of Danville VA
purchasing department.
My signature below certifies that:
* I agree to abide by all conditions of this Proposal and that I am authorized to sign this Proposal.
* The accompanying proposal is not the result of, or affected by, any unlawful act of collusion with another person or
company engaged in the same line of business or commerce, or any act of fraud punishable under Title 18.2, Chapter
12, 498.4 of the Code of Virginia, 1950 as amended. Furthermore, I understand that fraud and unlawful collusion are
crimes under the Virginia Governmental Frauds Act, the Virginia Government Bid Rigging Act, the Virginia Antitrust Act,
and Federal Law, and can result in fines, prison sentences, and civil damage awards.
* The accompanying proposal is in compliance with the State and Local Government Conflict of Interests Act 2.2-3100,
supplemented by Article 6, 2.2-4367-69 of the Code of Virginia. Specifically, no City of Danville employee, City of
Danville employee's partner, or any member of the City of Danville employee's immediate family holds a position with
the offeror such as an officer, director, trustee, partner or the like, or is employed in a capacity involving personal and
substantial participation in the procurement transaction, or owns or controls an interest of more than five percent.
To receive consideration for award, this signature sheet must be returned to the Purchasing Department as it shall be a part
of your response.
PLEASE COMPLETE THE FOLLOWING INFORMATION:
Complete Legal Name of Firm:
Address:
Federal Tax ID Number:
Signature of Authorized Representative:
Typed Name and Title:
Please provide the primary contact person for questions and concerns relative to this project:
Contact Name and Title:
Phone: ( ) Fax: ( ) Email:
We hereby provide the following information to the City of Danville, VA purchasing department regarding our
business. We understand that it is provided for statistical purposes only and all firms submitting proposals will
receive equal consideration.
Minority-Owned Business: YES NO City of Danville YES NO
Business:
Women-Owned Business: YES NO Small Business YES NO
Service Disabled Veteran-Owned Business: YES NO