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10. PRE -QUALIFICATION CHECKLIST (FOR BIDDERS THAT ARE NOTPRE+QUAUFED) <br />(a) <br />W L By checking this box, U hereby acknowledge that | am not a pre -qualified bidder <br />with the City ofSouth Bend. <br />(||) _w' By checking this box. | hereby acknowledge that the City reserves the right to <br />request supplemental information, additional verification of any information <br />provided, and may also conduct random |mqm|des of my current and prior <br />customers. The City reserved the right to utilize all information provided in this <br />submission and all information obtained in inquiries or requests to determine if a <br />bidder is responsive and responsible. Additionally, | acknowledge that all <br />information provided buthe City shall baregarded aupublic records. <br />L� By checking this box. | hereby acknowledge that copies of all Applicable <br />apprenticeship certificates or standards for training programs applicable to the <br />work performed on the project may be requested at any time and nheU be <br />furnished upon request, <br />(iv) � By checking this box, | hereby acknowledge and ensure that | and all sub- <br />contractors, from! whom | have accepted o bid and/or intend to hire to perform <br />work on the public work pnoject, are properly licensed. Furthermore, | <br />acknowledge myunderstanding that itimmyresponsibility toensure that all sub- <br />contractors have the necessary licenses toundertake the work called for in this <br />bid. If a sub -contractor loses their license at any point, it is the nympunaibiDh/ of <br />that sub -contractor bmnotify the City. <br />(b) Attachments: <br />(i) ~ <br />Indiana Secretary of Stahe'a on-line records (ie. Business verification) dated <br />within sixty (G0)days ofthe submission nfsaid document showing that business <br />is in existeoon, current with the Indiana Secretary of State'm Business Entity <br />Report, and eligible for a oerhfioeha of good standing. (Not applicable to <br />individuals, soKeproprietors orpodmemhipe). <br />(ii) Li <br />List identifying all former business names. <br />(iii) PIA <br />Any determinations by a court or governmental agency any violations of federal <br />state, or |aoe| laws including, but not limited to, violations of contracting or <br />antitrust laws, tax or licensing laws, environmental laws, Occupational Safety and <br />Health Act ((]SHA), or federal Davis -Bacon and related Acts, w|dl|n the <br />pnec��ing�v�(�)ye�rs . <br />(iv) ��_ <br />Statement about staffing capabilities, including labor sources. This statement <br />indicates and ensures |have sufficient employees onstaff bocomplete the work | <br />am bidding on OR outlines how I intend to meet the staffing needs of the work. <br />M i� <br />Statement that individuals who will perform work on the public work project on my <br />behalf will bmproperly classified amanemployee orommnindependent contractor <br />under all applicable state and federal laws and local ordinances. <br />(v|) V., <br />Evidence of participation, in apprenticeship and training proQnmmm, applicable to <br />the work tu be performed on the projeot, which are approved by and registered <br />with the United States Department of Labor'u Office of Apprenticeship, or its <br />successor . <br />(vii} <br />Copy ofawritten plan for employee drug testing that covers all ofmyemployees <br />who will perform work on the public work project and meets mrexoeede the <br />w^ <br />requirements set forth im |C4-13'i8-5or|C4'i3'18-8. <br />(viil) _c_ <br />Evidence that U am utilizing a surety company which is on the Bureau of Fiscal <br />Service "Department of Treasury's Lisfing of Approved Sureties" as required in <br />the bid specifications orcontract. <br />\ersiun712O/2018 General Conditions -10 <br />