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Home My WebLink AboutContract 55172 CSC No.661T2 Dallas,TX 75243 Fax: 214-363-2445 � EQUIPMENT RENTAL AGREEMENT � This Rental Agreement$entered into between OVMedical(hereinafter referred toos1Company and the person m company m listed below (hereinafter referred mosTlien,")for the rental and use Yf the following items(hereinafter referred mos"Equipment"): Date:_ Source_ of Business:_ _ MOD Modular Ramp Sys. MWIC Manual Wheelchair Name: Last 1�1_0y_ First TIC Transport Chair � POV Scooter Equipment CVI Medical Number/SKU D/W/M WK Walker FEB Full Electric Bed SEB Semi-Electric Bed PIL Patient Lift TRAP Trapeze LC Lift Chair Delivery k/16-5— RP Ramp � V/1, Client has chosen and agrees this is a CASH RENTAL and NO INSURANCE will be OTH Other Item filed byCV| Medical even if CV| Medical isa contracted provider for the Client's insurance. Terms and Conditions IV IV Pole CV1 Technicians have performed a safety assessment,cleaned,and sanitized the equipment.The client has been informed of the hours of operation and that afterhours phone calls will be returned the next business day.The client should call CV1 Medical to register a complaint or if they are injured when using the equipment. The client agrees they will use the above described equipment upon the express condition it will always remain the property of CVI Medical. The client agrees they will return the equipment at the completion of the rental period in the same excellent condition that they received it. The client further agrees and understands if the above equipment is not returned,the client agrees to pay CV1 Medical,the retailphce~~nftheeqmpment. The client is required to keep valid credit card information on file with CV1 Medical and that CVI Medical will use that information to extend rentals ortn sell the equipment to the client. The client acknowledges the responsibility for proper operation of equipment and acknowledges that they have been instructed in the safe operation of the equipment. The undersigned person agrees that,if they are not the designated user/client of this equipment,the undersigned is responsible for providing instruction on the safe operation of the equipment and adhere to all the conditions in the rental agreement.The client further agrees to indemnify and hold harmless the supplier,CV1 Medical,from and against any and all claims of loss and/or and possession vf said equipment to others and the user. Client Signature: Date: Name and signaturem�nson accepting delivery on behalf m the user. OFFICIAL RECORD Name: CITY SECRETARY FT.WORTH, TX Signature: Date: "Retail Price of Rental Equipment:The retail price of rental equipment shall be determined by the lowest purchase price that can be found""the Internet for the same product or product that/,similar but not inferior w the product rented. A$u handling charge will be added to the retail price to cover the administrative cost of ordering"replacement product and placing the item m the cm Medical rental system. FORT WORTH CITY OF FORT WORTH LEASE AGREEMENT ADDENDUM This LEASE AGREEMENT ADDENDUM ("Agreement") is entered into by and between Cm m blgll[("Vendor") and the City of Fort Worth, ("City"), a Texas home rule municipality. The Agreement includes the following documents which shall be construed in the order of precedence in which they are listed: l. This Agreement; 2. Exhibit A—Vendor's Quote, Scope of Services, and Vendor's Terms and Conditions; 3. Exhibit B—Conflict of Interest Questionnaire. Exhibits A and B, which are attached hereto and incorporated herein, are made a part of this Agreement for all purposes. Vendor agrees to provide City with the services and goods included in Exhibit A pursuant to the terms and conditions of this Cooperative Purchase Agreement, including all exhibits thereto. City shall pay Vendor in accordance with the fee schedule in Exhibit A and in accordance with the provisions of this Agreement. Total payment made under this Agreement for the first year by City shall be in the amount of-tuo-_T.6wsgb.,aw ovy 4blMtDollars ($ . Vendor shall not provide any additional items or services or bill for expenses incurred for City not specified by this Agreement unless City requests and approves in writing the additional costs for such services. City shall not be liable for any additional expenses of Vendor not specified by this Agreement unless City first approves such expenses in writing. Vendor agrees that City shall,until the expiration of three(3)years after final payment under this Agreement, or the final conclusion of any audit commenced during the said three years, have access to and the right to examine at reasonable times any directly pertinent books,documents,papers and records, including, but not limited to, all electronic records, of Vendor involving transactions relating to this Agreement at no additional cost to City. Vendor agrees that City shall have access during normal working hours to all necessary Vendor facilities and shall be provided adequate and appropriate work space in order to conduct audits in compliance with the provisions of this section. City shall give Vendor reasonable advance notice of intended audits. In compliance with Article 11 § 5 of the Texas Constitution, it is understood and agreed that all obligations of City hereunder are subject to the availability of funds. If such funds are not appropriated or become unavailable,City shall have the right to terminate the Agreement except for those portions of funds which have been appropriated prior to termination. Notices required pursuant to the provisions of this Agreement shall be conclusively determined to have been delivered when (1) hand-delivered to the other party, its agents, employees, servants or representatives, (2) delivered by facsimile with electronic confirmation of the transmission, or (3) received by the other party by United States Mail, registered, return receipt requested, addressed as follows: To CITY: To VENDOR: City of Fort Worth YVI6 IcAt" , Attn: Valerie Washington, Assistant City tt Title Manager 0*-Ct, MAtt4e r 200 Texas Street itu m N•CE 9 l li,l)ai&vey, Fort Worth, TX 76102-6314 Facsimile: 24k-S&-4 -4-57-43 Facsimile: (817) 392-8654 With copy to Fort Worth City Attorney's Office at same address The undersigned represents and warrants that he or she has the power and authority to execute this Agreement and bind the respective Vendor. CITY OF FORT WORTH: CONTRACT COMPLIANCE MANAGER: ym�y/e iV9fhA1a401f By signing I acknowledge that I am the person By: Valerie Washington(Jan 15,2 110:107 responsible for the monitoring and administration Name: Valerie Washington of this contract, including ensuring all performance Title: Assistant City Manager and reporting requirements. Date: Jan 15,2021 APPROVAL RECOMMENDED: By: in Cox(Jan13,202117:5 csT) Name: Justin Cox Title: Grants Manager .-,ilJan 15,202107:a1 C5T)By: it APPROVED AS TO FORM AND LEGALITY: Name: James Davis Title: Fire Chief p `*o. -�o'-' p°o0° ATTEST: oo�� By: c-s1. .40 Name: Taylor Paris n/�,�� o _° Title: Assistant City Attorney 'jl"�� TEX ASbOp� By: v ��aaaaa� CONTRACT AUTHORIZATION: Name: Mary Kayser M&C: Not required Title: City Secretary VENDOR: i iCIOL ATTEST: � � r By: Name: COUCARGI fJ By: 4,eW4�)4� Title: I Cr VA ANC EV2 Name: (f� _ < r��c / _j Title: — OFFICIAL RECORD Date: CITY SECRETARY FT.WORTH, TX CONFLICT OF INTEREST QUESTIONNAIRE FORM CIO For vendor doing business with local governmental entity This questionnaire rstiscts changes wds to the Ise by Ke. 23,84th Lop., Repulsr Session. OFFICE USE ONLY This questionnaire is being filed in accordance with Chapter 176,Local Government Code, Dw,Aacm,,d by a vandorwho has a business relationship as defined by Section 176.001(1-a)with a local governmental entity and the vendor meets requirements under Section 176.006(a). By law this questionnaire must be tiled with the records administrator of tle bcd govarrrrental entity not later than the 7th business day after the date the vendor becomes aware of facts that require the statement to be filed. Soo Section 176.006(a-1),Local Government Code. A vendor commits an offense if the vendor knowingly violates Section 176.006. Local Govemment Code.An offense under this section is a misdemeanor. Name of vendor who has a business relationship with local govemmental entity. PIWMA-V-- SIJ GTRN a5 l 'D Chit rb ti(-R-k- Check this box If you are tiling an update to a previously filed questionnaire. (The law requires that you file an updated completed questionnaire with the appropr,ate filing authonly not later than the 7th business day after the date on which you became aware that the originally filed queetxxvm we was incomplete or inaccurate.) Name of local government officer about whom the Information in thin section Is be"disclosed. Name of Officer This section(item 3 including subparts A, R C. 3 D) must be completed for each officer with whom the vender has an employment or other business relathonslup as defined by Section 176 001(1-a),Local Government Code. Attach additional pages to this Form CIO as necessary. A. Is the local government officer named in this section receiving or lilcsty to receive taxable ihcortne,other than emvestment income,from the vendor? Yes No B. Is the vendor receiving or Wwly to receive taxable income,other than wNeshnent income,from or et the derection of the local government officer named in this section AND the taxable income is not received from the local governmental ently? aYea n No C. Is the filer of this questionnaire employed by a corporation or other business entity with rasped to which the local goverment officer serves as an officer or director,or holds an ownership kitwest of one percent or mare? a Yes �� No D. Describe each employment or�'usiness and family relationship with the local government officer named in this section. S.gna6ure of vendor doing business with are gi r imrherxal anDy D Adopted 8/7/2015