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1 <br />W _g_ By checking this box, I hereby acknowledge that I am not a pre -qualified bidder <br />with the City f'SouthBend. <br />(ii) 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,andmay also conduct imy 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, I acknowledge that all <br />information provided to the City shall be regarded as public records. <br />(iii) X By checking this box, I hereby acknowledge that copies of all Applicable <br />apprenticeship certificatesor f!. 1 for training programs applicableto the <br />work performed on the project may be requested at any time and shall be furnished <br />upon 1 <br />:checkingthisbox, f acknowledge fensure that I andall sub- <br />contractors,M ohave accepted a bidand/ori1 to hire to perform <br />on the public work project, are properly. licensed. Furthermore, I acknowledge my <br />understanding if ( to ensure that all sub -contractors <br />the necessary - • undertake the work called for in this • f If a sub- <br />contractorf point, it is the responsibilityof that sub- <br />contractorto notify <br />(b) Attachments: <br />(i) x <br />Indiana Secretary of State's on-line records (i.e. 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 a certificate of good standing. (Not applicable to individuals, sole <br />proprietors or partnerships). <br />List identifying all former business names. <br />X <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 />laws, tax or licensing laws, environmental laws, 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) x <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 />Evidence of participation in apprenticeship and training programs, applicable to the <br />work to be performed on the project, which are approved by and registered with <br />the United States Department of Labor's Office of Apprenticeship, or its successor <br />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 IC 4-13-18-5 or IC 4-13-18-6. <br />(viii) X <br />Evidence that I am utilizing a 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 or contract. <br />Version 712=018 General Condltions - 9 <br />