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P CHECKLIST (FOR BIDDERS THAT ARE NOT PRE-QVJAUFIE[) <br />(a) Acknow| ame�s: <br />W �^ <br />By checking this box, | hereby acknowledge that |emnot opre-qualified bidder <br />_u� <br />with the City ofSouth Bend. <br />00 �� <br />Bychecking this box, | hereby acknowledge that the City reserves the right to <br />request supplemental infonnation, additional verification of any information <br />pruvided, 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 oepublic records. <br />(iii) _Z <br />By checking this box. | hereby acknowledge that copies of all Applicable <br />apprenticeship certificates orstandards for training programs applicable hothe <br />work performed on the project may be requested at any time and shall be furnished <br />_�. <br />uponvequeot . <br />(k) <br />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, are properly licensed. Furthermore, | acknowledge nny <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 ofthat sub- <br />contractor tmnotify the City. <br />(b) Attach <br />(i) 2 <br />Indiana Secretary of State's on-line records (ie. Business verification) dated within <br />sixty (GO) days of the submission of said document showing that business is in <br />existenoe, current with the Indiana Secretary ofState's Business Entity Report, <br />and eligible fora cedifinoba of good standing. (Not applicable to individua|n, sole <br />proprietors or partnerships). <br />List identifying all former business names. <br />Any determinations by o court or governmental agency any violations of federal <br />etota, orlocal laws including, but not limited to, violations ofcontracting orantitrust <br />|ewm. tax orlicensing laws, environmental laws, Occupational Safety and Health <br />Act (OSHA), or federal Davis -Bacon and related Acts, within the preceding five (5) <br />(k) <br />. <br />years. <br />Statement about staffing copabi|itiem, including labor sources. This statement <br />indicates and ensures I have sufficient employees on staff to complete the work I <br />.� <br />ambidding onDRoutlines how | intend tomeet the staffing needs ofthe 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 />- <br />underoUapp|icob|oo�nb*andfadena||awmond|ou�|ordinance� . <br />(vi) ��_ <br />For every pnoject, submit evidence cfparticipation in apprenticeship and training <br />proQramo, applicable to the work to be pedbnnad on the puojeot, which are <br />approved by and registered with the United States Department of Labor's Ofrice of <br />=�r <br />Apprenticeship, orits successor organization. <br />(vii) _�� <br />Copy ofawritten plan for employee drug testing that covers all nfmyemployees <br />who will perform work on the public work project and meets or exceeds the <br />-u� <br />requirements set forth in |C4-13-1O-6or|C4-13-18-G' <br />(viii) ��_ <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 />Version5/18/2U19 General Conditions 'S <br />