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CHECKLIST (FOR BIDDERS THAT ARE NOT PRE -QUALIFIED) <br />(a) <br />W ___ By checking this box, | hereby acknowledge that | am not pre -qualified bidder <br />with the City of South Bend. <br />(/; __ By checking this box, i hereby acknowledge that the City reserves the right to <br />request supplemental |nfnnnation, additional verification of any information <br />pnoxded, 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 noappnoiwa and responsible. Additionally, | acknowledge that all <br />information provided 0nthe City shall bwregarded oapublic records. <br />(iii) By checking this bon. I hereby acknowledge that copies of all Applicable <br />apprenticeship certificates or standards for training programs epp||uabka 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 mnaunw that | and all sub- <br />contractors, from whom I have accepted a bid and/or intend to hire to perform work <br />unthe 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 called for in this bid. If sub- <br />contractor loses their license at any poirt, it is the responsibility of that sub- <br />contractor tonotify the City. <br />M ___ By checking this bcx. U hereby acknowledge that apprenticeship and training <br />programs that | participate inhave graduated mtleast five (5)apprentices ineach <br />mYthe past five (5)years. <br />(wi) 8ychecking this box, I hereby acknowledge that all subcontractors performing <br />work greater than $250, 000 also meet the qualifications of the Responsible Bidder <br />Ordinance. <br />(b) Attachments: <br />N __ <br />Indiana Secretary ofQtato on-line records (i.e.. Business verification) dated <br />within sixty (60) days of the submission of said document showing that business is <br />in existence, current with the Indiana Secretary of State's Business Entity Report, <br />and eligible for o certificate of good standing. (Not applicable to individua}s, sole <br />proprietors orpmrtnemhips). <br />List identifying all former business names. <br />Any determinations by a court or governmental agency any violations of federal <br />state, orlocal laws including, but not limited to, violations ofcontracting orantitrust <br />laws, tax cnlicensing |ewe. environmental |owm. Occupational Safety and Health <br />Act (OSHA).orfederal Davis -Bacon and related Acts, within the preceding five (5) <br />years. <br />(k) <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 />ambidding wnORoutlines how | intend b»meet the staffing needs oYthe work. <br />(v) <br />Statement that individuals who will perform work on the public work project on my <br />behalf will be properlyclassified oomnemployee nramanindependent contractor <br />under all applicable state and federal laws and local ordinances. <br />(vi) <br />For every project, submit evidence of participation in apprenticeship and training <br />progmmmm, applicable to the mmrh to be performed on the pnoject, which are <br />approved by d registeredwiththoUnitedStatenOaportmmntoiLobo/nOffipoof <br />Apprenticeship, mrits successor organization. <br />(vii) <br />Copy of a written plan for employee drug testing that covers all of my employees <br />VorsionS/20/2O24 General Conditions -13 <br />