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U. PRE -QUALIFICATION CHECKLIST (FOR BIDDERS THAT ARE NOT PRE -QUALIFIED) <br />(a) Acknowledgements: <br />(0 ___ By checking this box | hereby acknowledge that | am note pre -qualified bidder <br />with the City ofSouth Bend. <br />(ii) By checking this box. | hereby acknowledge that the City reserves the right to <br />request supplemental infomnetion, additional verification of any information <br />provided' and may also conduct random inquiries of my current and prior <br />customers. The City nanen/ed the right to utilize all information provided in this <br />submission and all information obtained in inquiries or naquaoto to determine if <br />bidder is responsive and responsible. Additionally, | acknowledge that all <br />information provided tothe City shall beregarded eapublic records. <br />(iii) 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 shall be furnished <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, are properly licensed. 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 co||od for in this bid. If sub- <br />contractor |oeoo their license at any point, it in the naepono|b|||ty of that sub- <br />contractor to notify the City. <br />(b) Attachments: <br />(i) ___ <br />Indiana Secretary of8bate/a on-line records (i.e.. Business verification) dated <br />within <br />sixty (00) days of the submission of said document showing that business is in <br />ex|abanoe' current with the Indiana Secretary of8tota'o Business Entity Report, <br />and eligible for a certificate of good standing. (Not applicable to |ndividue|a, sole <br />proprietors orpertnaeh|po). <br />(ii) <br />List identifying all former business names. <br />(iii) <br />Any determinations by a court or governmental agency any violations of federal <br />state, or local laws ino|uding, but not limited to, violations of contracting or antitrust <br />|owa' tax or licensing laws, environmental |oea. Occupational 8e#*ty and Health <br />Act (OSHA), or federal Davis -Bacon and related Acto, within the preceding five (5) <br />years. <br />(iv) <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 />(v|) <br />For every project, submit evidence of participation in apprenticeship and training <br />pnognama, 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) <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 |C 4'13-18'5 or |C 4'13'18-8. <br />(viii) <br />Evidence that | am utilizing e 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 />\Aeroion1Q/13/2O21 General Conditions '13 <br />