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CHECKLIST (FOR BIDDERS THAT ARE NOT PRE -QUALIFIED) <br />(a) <br />0) ___ 8ychecking this box, | hereby acknowledge that omnot epre-qualified bidder <br />with the City ofSouth Bend. <br />(ii) __ By checking this box. | hereby acknowledge that the City reservestho right to <br />request supplemental infonneUun, additional verification of any information <br />pnovided, 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 <br />bidder is responsive and responsible. Additionally, | acknowledge that all <br />information provided bothe City shall baregarded onpublic 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. I 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 property 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 oa|kod for in this bid. If a sub- <br />contractor |omao their license at any point, it is the responsibility of that sub- <br />contractor bonotify the City. <br />M _ By checking this box, | hereby acknowledge that apprenticeship and training <br />programs that | participate inhave graduated atleast five (5)apprentices ineach <br />ofthe past five (5)years. <br />(»0 By checking this box. | hereby acknowledge that all subcontractors performing <br />work greater than $2SO.0UOalso meet the qualifications ofthe Responsible Bidder <br />Ordinance. <br />(b) Attachments: <br />N __ Indiana Secretary of Stote'mon-line records (ie. Business verification) dated within <br />sixty (60) days of the submission of said document showing that business is in <br />exinbence, current with the Indiana Secretary ofSteta'o Business Entity Repnrt, <br />and eligible for a certificate of good standing. (Not applicable to individua|m, sole <br />proprietors orportnenohipo). <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 />|ewo. tax orlicensing laws, environmental |mwm. Occupational Safety and Health <br />Act (OSHA), or federal Davis -Bacon and related Acts, within the preceding five (5) <br />years. <br />(iv) ___ 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 unORoutlines how | intend bomeet the staffing needs ofthe work. <br />(v) ___ Statement that individuals who will perform work on the public work project on my <br />behalf will baproperty daeoifiadasanemployee orewenindependent contractor <br />under all applicable state and federal laws and local ordinances, <br />(v) ___ For every project, submit evidence of participation in apprenticeship and training <br />pnognams, applicable bothe work to be performed on the pnojeot, which are <br />approved by and registered with the United States Department of Labors Office of <br />Apprenticeship, or its successor organization. This includes, but may not be limited <br />to, letters from apprenticeship coordinators detailing the bidder's association with <br />Versiun5/2V/2V24 General Conditions -14 <br />