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O. CHECKLIST (FOR BIDDERS THAT ARE NOT PRE-QUAL|FlE0) <br />(o)Acknowledgements: <br />W ___ By checking this box | hereby acknowledge �nthat| am not a pre -qualified bidder <br />with the City of South Bend. <br />(i0 ___ Bychecking this box, | hereby acknowledgedvright <br />request supplemental information, additionalverification <br />^ of any information <br />prmvided, and may also conduct random inquiries of my � current and prior <br />customers. The City reserved the right �o w���� all information --t/mn provided in this <br />submission and all inf <br />ormation requests todetermine ifo <br />bidder isresponsive and responsible. Additionally, (aow|adQe that all <br />information provided tmthe City shall beregarded aspublic noonndo <br />(i//) By checking this box, I hereby acknowledge that copies <br />~"-"f all Applicable <br />apprenticeship certificates orstandards for trainin <br />g pnugnomo applicable tothe <br />work performed omthe project may barequested atany time and shall bofurnished <br />upon request. <br />(iv) By checking this box. | hereby acknowledge and onouno that | and all sub- <br />contractors, from whom I have accepted a bid and/or intend to hire to perform work <br />on the pwbHc work project, are, properly licensed. Furthermore, [ acknowledge my <br />understanding that itimnny responsibility 0#ensure that all sub -con tractors have <br />the necessary licenses to undertake the work called for /n this bid If sub- <br />contractor /ooan their license at any point. it is the responsibility of that sub- <br />contractor to notify the City. <br />M Attachments: <br />(0 <br />Indiana Secretary nfState/mon-line records (ie. Business verification) da�dw�hin <br />sixty�) days of the submission of saidd�u�� showingthat^ business is in <br />existence, mummrt with the Indiana Secretary of 8taba'o Business Entity � Report,, <br />and eligible for a certificate of good standing. (Not applicable to /n U`i�--�|o sole <br />-- <br />pmp�ebomorpa�noruhipo). ' <br />List identifying all former business names. <br />Any determinations by a court or governmental agency any violations of federal <br />atate, orlocal laws including, but not limited to, violations of contracting or antitrust <br />|awo, tax urlicensing laws, environmental laws, Occupational Safety and Health <br />Act (OSHA), or federal Davis -Bacon and related Acts, within the preceding five (5) <br />(iv) <br />years. <br />Statement about staffing capabilities, including labor sources. This statement <br />indicates and ensures | have sufficient employees onto <br />(v} <br />staff complete thework| <br />ambidding onORoutlines how | intend tomeet the staffing needs 'ofthe work. <br />Statement <br />that individuals who will perform work onthe public ~~ project 'eotonmy <br />behalf will beproperly classified mocamn m�p|oyeeoraeanindependent~mmtnecbor <br />(vi) <br />under all applicable state and federal laws and local ordinances. <br />For <br />every project, aubmitevidenomofpadicipaUonimappnanUshipondhaim|ng <br />p,mgmamo, applicable to the work to be Performed on the project, which are <br />approved byand registered vvdhthe United States Depa�mnento-''~ab`~r`mOffice of <br />Apprenticeship, orits successor orQamiza0mm <br />NO___ <br />Copy of a w�henplan for employee drug testing that covers all ofmyemployees <br />who will perform work on the public work project and meets or exceeds the <br />requirements set forth in IC 4-13-18-5 or|C4-13-18~6 <br />(viii) ___ <br />Evidence that | am utilizing,a ounuhy company which is on the Bureau of Fiscal <br />Service "Department of Treasury's Listing of Approved Sureties" as required in the <br />bid specifications orcontract, <br />