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N. PRE -QUALIFICATION CHECKLIST (FOR BIDDERS THAT ARE NOT PRE~Q#JALF|ED) <br />(a) Acknowledgments: <br />(i> J{ By checking this box. | hereby acknowledge that | am not pre -qualified bidder <br />with the City OfSouth Bend. <br />(ii) 2{ By checking this box, I 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 inquiries 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 tothe City shall beregarded aapublic records. <br />(iii) X 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 onthe project nnuyberequestadotanyUm*andeha||befurniehed <br />upon request. <br />(iv) }{ By checking this box. | hereby acknowledge and ensure that | and all sub- <br />contractors, from whom I have accepted a bid and/or intend to hire to perform work <br />onthe public work project, aropropedy|ioenaed. Furthermore, | acknowledge my <br />understanding 'that it is my responsibility to ensure that all sub -contractors have <br />the necessary licenses to undertake the work called for in this bid. If sub- <br />contractor loses their license at any point, it is the responsibility of that sub- <br />contractor to notify the City. <br />(h) Attachments: <br />(i) X <br />Indiana Secretary of State's on-line records (ie. Business verification) dated within <br />sixty (60) days of the submission of said document showing that business is in <br />existence' current with the Indiana Secretary of State`s Business Entity Report, <br />and eligible for u certificate of good standing. (Nod applicable to individuals, sole <br />proprietors orpartnenships). <br />(ii) X <br />List identifying all former business names. <br />(iii) X <br />Any determinations by o court or governmental agency any violations of federal <br />state, or local laws including, but not limited to, violations of contracting or antitrust <br />|ewm. tax nrlicensing |omm. environmental (awe` Occupational Safety and Health <br />Act (OSHA), or federal Davis -Bacon and related Acts, within the preceding five (5) <br />years. <br />(iv) X <br />Statement about staffing capabilities, including labor sources. This statement <br />indicates and ensures I have sufficient employees on staff to complete the work I <br />am bidding on OR outlines how I intend to meet the staffing needs of the work. <br />(v) % <br />Statement that individuals who will perform work on the public work project on my <br />behalf will be properly classified as an employee or as an independent contractor <br />under all applicable state and federal laws and local ordinances. <br />(vi) X <br />For every project, submit evidence of participation in apprenticeship and training <br />pnognanna, applicable to the work to be performed on the project, which are <br />approved by and registered with the United States Department of Labor's Office of <br />Apprenticeship, orits successor organization. <br />(vii) X <br />Copy of a written plan for employee drug testing that covers all of my employees <br />who will perform work on the public work project and meets or exceeds the <br />requirements set forth in |[|4-13-18-5ur|C4-13-1O-S. <br />/viii\ X <br />Evidence that | am utilizing o surety 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 />VersionO1C2S/202U General Conditions -9 <br />