If the Professional Service Entity is an INDIVIDUAL, sign name and give the following information:
Name: ______________________________________________________________________________
Address: ______________________________________________________________________________
Telephone No.: ____________________________Social Security No.:_____________________________
Fax No.: ______________________________ E-Mail: ________________________________________
If individual has a TRADE NAME, give such trade name:
Trading As: _______________________________________ Telephone No.: ________________________
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If the Professional Service Entity is a PARTNERSHIP, give the following information:
Name of Partners: _______________________________________________________________________
Firm Name: _______________________________________________________________________
Address: _______________________________________________________________________
Telephone No.: ____________________________ Federal I.D. No.: _______________________________
Fax No.: ______________________________ E-Mail: _________________________________________
Social Security No.: ____________________________________________________________________
Signature of authorized agent: _____________________________________________________________
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If the Professional Service Entity is INCORPORATED, give the following information:
State under whose laws incorporated: ______________________________________________________
Location of principal office: ______________________________________________________________
Telephone No.: __________________________ Federal I.D. No.: ________________________________
Fax No.: _______________________________ E-Mail:_______________________________________
Name of agent in charge of said office upon whom notice may be legally served:
_____________________________________________________________________________________
Telephone No.: _________________________Name of Corporation: ______________________________
Signature: By: ____________________________________
Title: Address: ___________________________________________
SUBMISSION FORM
1. Names and roles of the individuals who will perform the services and description of their education and experience with projects similar to the services contained herein including their education, degrees and certifications:
2. References and record of success of same or similar service:
3. Description of ability to provide the services in a timely fashion (including staffing, familiarity and location of key staff):
4. Cost details, including the hourly rates of each of the individuals who will perform services, and all expenses:
Note: Attach additional sheets as necessary.
Firm:_________________________________________ Date: _________
Authorized Representative (Print):
_____________________________________________________
Signature: _____________________________ Title: _____________________
Telephone #: Fax #:
EXHIBIT A
MANDATORY EQUAL EMPLOYMENT OPPORTUNITY LANGUAGE
N.J.S.A. 10:5-31 et seq. and N.J.A.C. 17:27 et seq.
GOODS, PROFESSIONAL SERVICES AND GENERAL SERVICE CONTRACTS
During the performance of this contract, the contractor agrees as follows:
The contractor or subcontractor, where applicable, will not discriminate against any employee or applicant for employment because of age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, or sex. Except with respect to affectional or sexual orientation, the contractor will take affirmative action to ensure that such applicants are recruited and employed, and that employees are treated during employment, without regard to their age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, or sex. Such action shall include, but not be limited to the following: employment, upgrading, demotion, or transfer; recruitment or recruitment advertising, layoff or termination; rates of pay or other forms of compensation; and selection for training, including apprenticeship. The contractor agrees to post in conspicuous places, available to employees and applicants for employment, notices to be provided by the Public Agency Compliance Officer setting forth provisions of this non-discrimination clause.
The contractor or subcontractor, where applicable will, in all solicitations or advertisements for employees placed by or on behalf of the contractor, state that all qualified applicants will receive consideration for employment without regard to age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation or sex.
The contractor or subcontractor, where applicable, will send to each labor union or representative or workers with which it has a collective bargaining agreement or other contract or understanding, a notice, to be provided by the agency contracting officer advising the labor union or workers’ representative of the contractor's commitments under this act and shall post copies of the notice in conspicuous places available to employees and applicants for employment.
The contractor or subcontractor, where applicable, agrees to comply with any regulations promulgated by the Treasurer pursuant to N.J.S.A. 10:5-31 et seq., as amended and supplemented from time to time and the Americans with Disabilities Act.
The contractor or subcontractor agrees to attempt in good faith to employ minority and female workers consistent with the applicable county employment goals established in accordance with N.J.A.C. 17:27-5.2, or a binding determination of the applicable county employment goals determined by the Division, pursuant to N.J.A.C. 17:27-5.2.
The contractor or subcontractor agrees to inform in writing its appropriate recruitment agencies including, but not limited to, employment agencies, placement bureaus, colleges, universities, labor unions, that it does not discriminate on the basis of age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, or sex, and that it will discontinue the use of any recruitment agency which engages in direct or indirect discriminatory practices.
The contractor or subcontractor agrees to revise any of its testing procedures, if necessary, to assure that all personnel testing conforms with the principles of job-related testing, as established by the statutes and court decisions of the State of New Jersey and as established by applicable Federal law and applicable Federal court decisions.
In conforming with applicable employment goals, the contractor or subcontractor agrees to review all procedures relating to transfer, upgrading, downgrading and layoff to ensure that all such actions are taken without regard to age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, or sex, consistent with the statutes and court decisions of the State of New Jersey, and applicable Federal law and applicable Federal court decisions.
The contractor shall submit to the public agency, after notification of award but prior to execution of a goods and services contract, one of the following three documents:
Letter of Federal Affirmative Action Plan Approval
Certificate of Employee Information Report
Employee Information Report Form AA302
The contractor and its subcontractor shall furnish such reports or other documents to the Division of Contract Compliance & EEO as may be requested by the Division from time to time in order to carry out the purposes of these regulations, and public agencies shall furnish such information as may be requested by the Division of Contract Compliance & EEO for conducting a compliance investigation pursuant to Subchapter 10 of the Administrative Code at N.J.A.C. 17:27.
MANDATORY EQUAL EMPLOYMENT OPPORTUNITY NOTICE
(N.J.S.A. 10:5-31 et seq. and N.J.A.C. 17:27 et seq.)
This form is a summary of the successful professional service entity’s requirement to comply with the requirements of N.J.S.A. 10:5-31 et seq. and N.J.A.C. 17:27 et seq.
The successful professional service entity shall submit to the Borough of Englishtown, after notification of award but prior to execution of this contract, one of the following three documents as forms of evidence:
(a) A photocopy of a valid letter that the vendor is operating under an existing Federally approved or sanctioned affirmative action program (good for one year from the date of the letter);
OR
(b) A photocopy of a Certificate of Employee Information Report approval, issued in accordance with N.J.A.C. 17:27-1.1 et seq.;
OR
(c) A photocopy of an Employee Information Report (Form AA302) provided by the Division of Contract Compliance and distributed to the Borough of Englishtown to be completed by the vendor in accordance with N.J.A.C. 17:27-1.1 et seq.
The successful professional service entity may obtain the Employee Information Report (AA302) from the Borough of Englishtown during normal business hours.
The successful professional service entities must submit the white and canary copies of the AA302 (Employee Information Report) to the Division of Contract Compliance and Equal Employment Opportunity in Public Contracts (Division). The pink Public Agency copy is submitted to the Borough of Englishtown, and the gold Vendor copy is retained by the professional service entity.
The undersigned professional service entity certifies that he/she is aware of the commitment to comply with the requirements of N.J.S.A. 10:5-31 et seq. and N.J.A.C. 17:27 et seq. and agrees to furnish the required forms of evidence.
The undersigned professional service entity further understands that his/her submission shall be rejected as non-responsive if said professional service entity fails to comply with the requirements of N.J.S.A. 10:5-31 et seq. and N.J.A.C. 17:27 et seq.
COMPANY:
SIGNATURE:
PRINT NAME:
TITLE: DATE:
Borough of Englishtown
AMERICANS WITH DISABILITIES ACT OF 1990
EQUAL OPPORTUNITY FOR INDIVIDUALS WITH DISABILITY
The CONTRACTOR and the Borough of Englishtown (herein referred to as the Borough) do hereby agree that the provisions of Title 11 of the Americans With Disabilities Act of 1990 (the "Act") (42 U.S.C. S12101 et seg.), which prohibits discrimination on the basis of disability by public entities in all services, programs and activities provided or made available by public entities, and the rules and regulations promulgated pursuant thereunto, are made a part of this contract. In providing any aid, benefit, or service on behalf of the BOROUGH pursuant to this contract, the CONTRACTOR agrees that the performance shall be in strict compliance with the Act. In the event the CONTRACTOR, its agents, servants, employees, or subcontractors violate or are alleged to have violated the Act during the performance of this contract, the CONTRACTOR shall defend the BOROUGH in any action or administrative proceeding commenced pursuant to this Act. The CONTRACTOR shall indemnify, protect, and save harmless the BOROUGH, its agents, servants, and employees from and against any and all suits, claims, losses, demands, or damages of whatever kind or nature arising out of or claimed to arise out of the alleged violation. The CONTRACTOR shall, at its own expense, appear, defend, and pay any and all charges for legal services and any and all costs and other expenses arising from such action or administrative proceeding or incurred in connection therewith. In any and all complaints brought pursuant to the BOROUGH'S grievance procedure, the CONTRACTOR agrees to abide by any decision of the BOROUGH, which is rendered pursuant to, said grievance procedure. If any action or administrative proceeding results in an award of damages against the BOROUGH or if the BOROUGH incurs any expense to cure a violation of the ADA which has been brought pursuant to its grievance procedure, the CONTRACTOR shall satisfy and discharge the same at its own expense.
The BOROUGH shall, as soon as practicable after a claim has been made against it, give written notice thereof to the CONTRACTOR along with full and complete particulars of the claim. If any action or administrative proceeding is brought against the BOROUGH or any of its agents, servants, and employees, the BOROUGH shall expeditiously forward or have forwarded to the CONTRACTOR every demand, complaint, notice, summons, pleading, or other process received by the BOROUGH or its representatives.
It is expressly agreed and understood that any approval by the BOROUGH of the services provided by the CONTRACTOR pursuant to this contract will not relieve the CONTRACTOR of the obligation to comply with the Act and to defend, indemnify, protect, and save harmless the BOROUGH pursuant to this paragraph.
It is further agreed and understood that the BOROUGH assumes no obligation to indemnify or save harmless the CONTRACTOR, its agents, servants, employees and subcontractors for any claim which may arise out of their performance of this Agreement. Furthermore, the CONTRACTOR expressly understands and agrees that the provisions of this indemnification clause shall in no way limit the CONTRACTOR’S obligations assumed in this Agreement, nor shall they be construed to relieve the CONTRACTOR from any liability, nor preclude the BOROUGH from taking any other actions available to it under any other provisions of this Agreement or otherwise at law.
ATTENTION ALL PROFESSIONAL SERVICE ENTITIES
On June 29, 2004, Governor McGreevey signed P.L. 2004, c.57, Business Registration of Contractors with Government Agencies, into law. Effective September 1, 2004, all business organizations that do business with a local contracting agency (i.e. Borough of Englishtown) are required to be registered with the State of New Jersey, Department of Treasury, Division of Revenue, and provide proof of that registration to the contracting agency before the contracting agency may enter into a contract with the business.
A “Business Organization” means an individual, partnership, association, joint stock company, trust, corporation or other legal business entity or successor thereof.
The law provides that: A copy of the Business Registration Certificate issued by the NJ Department of Treasury, Division of Revenue, shall be provided at the time any submission is received; failure to do so is a fatal defect that cannot be cured. This law covers construction as well as non-construction submissions.
Further information may be obtained by visiting the following web site at the State of New Jersey: www.nj.gov/treasury/revenue/busregcert.htm
Goods & Services Contracts (including purchase orders):
N.J.S.A. 52:32-44 imposes the following requirements on contractors and all subcontractors that knowingly provide goods or perform services for a contractor fulfilling this contract:
1) The contractor shall provide written notice to its subcontractors and suppliers to submit proof of business registration to the contractor;
2) Prior to receipt of final payment from a contracting agency, a contractor must submit to the contracting agency an accurate list of all subcontractors or attest that none were used;
3) During the term of this contract, the contractor and its affiliates shall collect and remit, and shall notify all subcontractors and their affiliates, that they must collect and remit to the Director, New Jersey Division of Taxation, the use tax due pursuant to the Sales and Use Tax Act, (N.J.S.A. 54:32B-1 et seq.) on all sales of tangible personal property delivered into this State.
A contractor, subcontractor or supplier who fails to provide proof of business registration or provides false business registration information shall be liable to a penalty of $25 for each day of violation, not to exceed $50,000 for each business registration not properly provided or maintained under a contract with a contracting agency.
BOROUGH OF ENGLISHTOWN
NON-COLLUSION AFFIDAVIT
STATE OF NEW JERSEY :
: SS.
COUNTY OF :
I, ______________________________________ of the ________________of _________________________
in the County of ________________ and the State of New Jersey, of full age, being duly sworn according to law on my oath depose and say that:
I am ____________________________________________________________________________________
of the firm of ___________________________________________________________________
the Professional Service Entity making the submission for the above named Service, and that I executed the said submission with full authority to do so; that said Professional Service Entity has not, directly or indirectly, entered into any agreements, participated in any collusion, or otherwise taken any action in restraint of fair and open competition in connection with the above named Service; and that all statements contained in said submission and in this affidavit are true and correct, and made with full knowledge that the Borough of Englishtown relies upon the truth of the statements contained in said submission and in the statements contained in this affidavit in awarding the contract for said Service.
I further warrant that no person or selling agency has been employed or retained to solicit or secure such contract upon an agreement or understanding for a commission, percentage, brokerage or contingent fee, except bonafide employees or bonafide establish, commercial or selling agencies maintained by:
________________________________________________________________________________________
Name of Professional Service Entity
Subscribed and sworn to before me
this ____ _ day of _ ___ , 20___
____________________________________
Notary Public, State of __ __ ________________________________________
(Signature of Professional)
My Commission expires_________________ ________________________________________
(Type or Print name of affiant and Title, under signature)
BOROUGH OF ENGLISHTOWN
DISCLOSURE OF OWNERSHIP FORM
N.J.S.A. 52:25-24.2 reads in part that “no corporation or partnership shall be awarded any contract by the State, County, Municipality or School District, or any subsidiary or agency thereof, unless prior to the receipt of the submission of the corporation or partnership, there is provided to the public contracting unit a statement setting forth the names and addresses of all individual who own 10% or more of the stock or interest in the corporation or partnership”.
1. If the professional service entity is a partnership, then the statement shall set forth the names and addresses of all partners who own a 10% or greater interest in the partnership.
2. If the professional service entity is a corporation, then the statement shall set forth the names and addresses of all stockholders in the corporation who own 10% or more of its stock of any class.
3. If a corporation owns all or part of the stock of the corporation or partnership providing the submission, then the statement shall include a list of the stockholders who own 10% or more of the stock of any class of that corporation.
4. If the professional service entity is other than a corporation or partnership, the contractor shall indicate the form of corporate ownership as listed below.
COMPLETE ONE OF THE FOLLOWING STATEMENTS:
I. Stockholders or Partners owning 10% or more of the company providing the submission:
NAME: ADDRESS:
____________________________________________________________________
____________________________________________________________________
SIGNATURE:__________________________________DATE:______________
II. No Stockholder or Partner owns 10% or more of the company providing this submission:
SIGNATURE:__________________________________DATE:______________
III. Submission is being provided by an individual who operates as a sole proprietorship:
SIGNATURE:__________________________________DATE:______________
IV. Submission is being provided by a corporation or partnership that operates as a (check one of the following):
_______ Limited Partnership _______ Limited Liability Corporation
_______ Limited Liability Partnership _______ Subchapter S Corporation
SIGNATURE: DATE:
BOROUGH OF ENGLISHTOWN
INSURANCE REQUIREMENTS AND ACKNOWLEDGEMENT FORM
Certificate(s) of Insurance shall be filed with the Municipal Clerk’s Office upon award of contract by the Borough Council.
The minimum amount of insurance to be carried by the Professional Service Entity shall be as follows:
PROFESSIONAL LIABILITY INSURANCE
Limits shall be a minimum of $1,000,000.00 for each claim and $1,000,000.00 aggregate each policy period.
Acknowledgement of Insurance Requirement:
___________________________________________________________ (Signature) (Date)
____________________________________________________________
(Printed Name and Title)