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PRE -QUALIFICATION CHECKLIST (FOR BIDDERS THAT ARE NOT PRE -QUALIFIED) <br />(a) <br />N _AZ Bychecking this box, | hereby acknowledge that | am not pre -qualified bidder <br />with the City ofSouth Bend. <br />(ii) `V_ By checking this box. | hereby acknowledge that the City meen/ey the right to <br />request supplemental inhnnnotion, additional verification of any information <br />provided, and may also conduct random inquiries of my current and prior <br />customers. The City moomnx*d 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 naopnnmib|m. Additionally, | acknowledge that all <br />information provided tothe City shall bmrogardedampub|iurecords. <br />(i�) ��_ By checking this box. | hereby acknowledge that copies of all Applicable <br />apprenticeship certificates orstandards for training programs applicable hzthe <br />work performed on the project may be requested at any time and shall be furnished <br />upon request. <br />.� <br />(iv) <br />1 _ 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 my <br />understanding that it is my responsibility to ensure that all sub -contractors have <br />the naoaonmry 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 hunotify the City. <br />(b) Attachm� <br />Indiana Secretary of8tato on-line records (ie. Business verification) dated within <br />sixty (60) days of the submission of said document showing that business is in <br />wxisUynce, current with the Indiana Secretary ofState'm Business Entity Report, <br />and eligible for a certificate of good standing. (Not applicable to individuo|m, sole <br />proprietors orpartnarohipo). <br />List identifying all former business names. <br />Any determinations by a court or governmental agency any violations of federal <br />state, or local laws including, but not limited to, violations of contracting or antitrust <br />|awm, tax or licensing laws, environmental |awo. Occupational Safety and Health <br />Act (OSHA), or federal Davis -Bacon and related Acts, within the preceding five (5) <br />.� <br />(iv)�u_ <br />years. <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 />_ � <br />(v) <br />ambidding onORoudvw <br />inemhmw|in�ond(ume+�thest��ngnoedeofLhoo�. <br />Statement <br />��_ <br />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 />under mUapplicable obdeand federal laws and local ordinances. <br />For <br />(vi) _�� <br />every pnojed, submit evidence of participation in apprenticeship and training <br />pnogname, 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 />(vii) _ � <br />AppnenUcaship.or�asuccessor organ�aUon. <br />Copy <br />�[_ <br />of a written plan for employee drug testing that covers all of my employees <br />who will pedhmn work on the public work project and meets or exceeds the <br />^� <br />- - - � <br />rmquinammntoma1fo�hin|C4 13 18 5or|�4-13-18-S <br />(viii) ��_ <br />Evidence that | am utilizing a surety company which in on the Bureau of Fiscal <br />Service "Department of Treasury's Listing of Approved Sureties" as required in the <br />bid specifications orcontract, <br />VmmionV7/1S/2023 General Conditions -14 <br />