HomeMy WebLinkAboutContract 57455 CSC No. 57455
FORT WORTH
CITY OF FORT WORTH
COOPERATIVE PURCHASE AGREEMENT
This Cooperative Purchase Agreement("Agreement")is entered into by and between Dobie Supply,
LLC ("Vendor") and the City of Fort Worth, ("City"), a Texas home rule municipality.
The Cooperative Purchase Agreement includes the following documents which shall be construed in the
order of precedence in which they are listed:
1. This Cooperative Purchase Agreement;
2. Exhibit A— Seller's Quote, Scope of Services or Purchase Order;
3. Exhibit B—Cooperative Agency Contract BuyBoard 608-20; and
4. Exhibit C—Conflict of Interest Questionnaire
Exhibits A, B, and C,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 by City shall not
exceed the amount of Sixty Thousand Dollars ($60,000.00). 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.
The term of this Agreement is effective beginning on the date signed by the Assistant City
Manager below ("Effective Date") and expires on May 31, 2022. The City shall be able to renew this
agreement for one (1) one-year renewal option by written agreement of the parties.
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.
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:
OFFICIAL RECORD
CITY SECRETARY
FT.WORTH, TX
To CITY: To VENDOR:
City of Fort Worth Dobie Supply, LLC
Attn: Dana Burghdoff,Assistant City Manager Valera Byrd, Sales Manager
200 Texas ,Street
Fort Worth, TX 76102-6314 Address:
Facsimile: (817) 392-8654 601 Commercial Dr.
Buda, TX 78610
With copy to Fort Worth City Attorney's Office
at same address Facsimile: 512-444-0796
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:
pang 24L( hd%ff By signing I acknowledge that I am the person
By; Dana Burghdoff pr20,2022 19:41 CDT) responsible for the monitoring and administration
Name: Dana Burghdoff of this contract,including ensuring all
Title: Assistant City Manager performance and reporting requirements.
Date:
APPROVAL RECOMMENDED: By:
Name: Lakeesba Dodson
Title: Sr. Administrative Assistant
By: William Johnson(A9fl5,202215:26CDT) APPROVED AS TO FORM AND LEGALITY:
Nance: William M Johnson
Title: Transportation/Public Works Director
ATTEST: pO FORr� as By:
A O°°°°°°°0oo
y"
f o �d Name: Taylor Paris
0-o °o��d Title: Assistant City Attorney
7Gl`I`IG��G c1 C7000��GG v° =a
By; Jannette S.Goodall(Apr21,2022 07:05 CDT) 00000000°'C' CONTRACT AUTHORIZATION:
Name: Jannette Goodall aa�nExAsgap M&C: NIA
Title: City Secretary
VENDOR:
I
Dobie Supply,LLC
By:
Na c: Valera Byrd OFFICIAL RECORD
Title: Sales Manager
CITY SECRETARY
Date: I , `� FT.WORTH, TX
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® Exhibit B
P p Board
wCoaperative Purchasing
P.O. Box 400
Austin, TX 78767-0400
800,695.2919 / 512.467.0222 / Fax.800.211.5454
buyboard.com
April 29, 2020
Sent Via Email: val@dobiesupply.com
Valera Byrd
Dobie Supply, LLC
601 Commercial Drive
Buda, TX 78610
Welcome to BuyBoard!
Re: Notice of The Local Government Purchasing Cooperative Award
Proposal Name and Number: Highway Safety and Traffic Control Products, Proposal No. 608-20
Congratulations, The Local Government Purchasing Cooperative (Cooperative) has awarded your company a BuyBoard®
contract based on the above-referenced Proposal. The contract is effective 6/1/2020 through 5/31/2021, with two possible
one-year renewals. The contract documents are those identified in Section 3 of the General Terms and Conditions of the
specifications.
To view the items your company has been awarded, please review the proposal tabulation No. 608-20 on the following
web-site: www.buyboard.com/vendor. Only items marked as awarded to your company can be sold through the BuyBoard
contract. In addition, on this website you will find the membership list which will provide you with the names of all entities
with membership in our purchasing cooperative.
Enclosed with this letter you will find the following documents:
1. Vendor Quick Reference Guide 2. BuyBoard License and Identity Standards
You are advised that receipt of a purchase order directly from a Cooperative member is not within the
guidelines of the Cooperative.Accepting purchase orders directly from Cooperative members may result in a violation
of the State of Texas competitive bid statute and termination of this Cooperative BuyBoard contract. Therefore, all
purchase orders must be processed through the BuyBoard in order to comply. Please forward by email to
info@buyboard.com any order received directly from a Cooperative member. If you inadvertently process a purchase
order sent directly to you by a Cooperative member, please email the order info@buyboard.com and note it as RECORD
ONLY to prevent duplication.
As an awarded vendor a BuyBoard user id and password will be sent via e-mail 2 to 3 business days prior to
the start of your contract.
On behalf of the Texas Association of School Boards, we appreciate your interest in the Cooperative and we are looking
forward to your participation in the program. If you have any questions, please contact Cooperative Procurement Staff
at 800-695-2919.
Sincerely,
Arturo Salinas
Department Director, Cooperative Procurement
v.6.5
—�r— The Local Government Purchasing Cooperative is endorsed by the Texas Association of Schooi Boards,
I. = : Tea Texas Municipal League, Texas Association of Counties,and the Texas Association of School Administrators.
PWBoard
Cuqpvraffv&Purvhasing
12007 Research Boulevard •Austin,Texas 78759-2439 ' PH: 800-695-2919 • FAX: 800-211-5454 ' buvboard.com
PROPOSERrS AGREEMENT AND SIGNATURE
Proposal Name: Highway Safety and Traffic Proposal Due Date/Openinci Date and Time:
Control Products November 7, 2019 at 4:00 PM
Location of Proposal,Ooenina:
Texas Association of School Boards, Inc.
BuyBoard Department
Proposal Number: 608-20 12007 Research Blvd.
Austin,TX 78759
Anticipated Cooperative Board Mleetina Date:
Contract Time Period: ]une 1, 2020 through May April 2020
31, 2021 with two (2) possible one-year renewals.
Wo i w I �
Name of Proposing Comp n Date -
�1 Comrvt� c�a1 fir. I
Street Address Si ture of Authorized Company Official
Bula
. -79 I 6, VCA lam '-'�j 1"A
City, State, 21p Printed Name of Authorized Co pany Official
61 a-- �3 -i 3c-�D le
Telephone Number of Authorized Company Official Position or Title of Authorized Compa OfFcial
Fax Number of Authorized Company Official Federal ID Number
i
f
Page 8 of 63
Proposal Forms COMM/SVCS v.05.31.2019
Board
Cooperative Purchasing
12007 Research Boulevard • Austin,Texas 78759-2439 • PH: 800-695-2919 ' FAX: 800-211-5454 " bu boar .cam
�}VENDOR CONTACT INFORMATION
Name of Company: °Jo C, &�X 0- L
Vendor Proposal/Contract Contact Name: �J
Vendor Proposal/Contract Contact E-mail Address: l { �', �-{—
Vendor Contact Mailing Address for Proposal/Contract Notices: 1 Vn 5 T7` D " -aU V
Company Website: I/LM QVI LAP O0 SA • C"
Purchase Orders: All purchase orders from Cooperative members will be available through the Internet. Vendors need
Internet access and at least one e-mall address so that notification of new orders can be sent to the Internet contact when
a new purchase order arrives. An information guide will be provided to vendors to assist them with retrieving their orders.
Please select options bellow for receipt of purchase orders and provide the requested information:
I will use the internet to receive purchase orders at the following address: }
Purchase Order E-mail Address: w� ` -
Purchase Order Contact: M t'y( U Phone: ri ;L` 3 vt
Alternate Purchase Order E-mail Address: 0\j �:4 l L W1
Alternate Purchase Order Contact: QQ1 Phone: 1 U / 6` I — 1 5
❑ Purchase orders may be received by the Designated Dealer(s) identified on my company's Dealer
Designation form as provided to the Cooperative administrator. I understand that my company shall
remain responsible for the Contract and the performance of all Designated Dealers under and in
accordance with the Contract.
Request for Quotes ("RFO"): Cooperative members will send RFQs to you by e-mail. Please provide e-mail addresses
for the receipt of RFQs;
RFQ E-mail Address: 2. M C, s] I
RFQ Contact: VAY-a_ �� W Y Phone: 5 a —U 3 ^C1 3
Alternate RFQ E-mail Address: �v Val �Ciy c 1 P 0 � U . to _
Alternate RFQ Contact: kINOS Phone: l '" `1
Page 10 of 63
Proposal Forms COMM/SVCS v.05.31.2019
1
DuBoard®
Cauperative Purchasing
12007 Research Boulevard • Austin,Texas 78759-2439 • PH: 800-695-2919 • FAX: 800-211-5454 1 buyboard.com
Invoices: Your company will be billed monthly for the service fee due under a contract awarded under this Proposal
Invitation. All invoices are available on the BuyBoard website and e-mail notifications will be sent when they
are ready to be retrieved. Please provide the following address, contact and e-mail information for receipt of service fee
invoices and related communications:
Please choose only one (1) of the following options for receipt of invoices and provide the requested
information:
tK Service fee invoices and related communications should he provided directly to my company at:
Invoice Mailing address: ;72 on S . YJ Sj. # ��- aO()Department: J�C C C'uV1Vj\V-k-�
City: State: Zip Code:
Contact Name:„ i 1/� ��]�� Phone: 5 l 3, � G
— r Ll 1 4
Invoice Fax: �JI � `1"t ! i 0�4nvoice E-mail Address: fb i n
Alternative Invoice E-mail Address: ,l 1/1 L,D�Iyi
❑ In lieu of my company, I request and authorize all service fee invoices to be provided directly to the following billing
agent**:
Billing agent Mailing address: Department:
City: State: Zip Code:
Billing Agent Contact Name: Phone:
Billing Agent Fax: Billing Agent E-mail Address:
Alternative Billing Agent E-mail Address:
**If Vendor authorizes a billing agent to receive and process service fee invoices, in accordance with the
General Terms and Conditions of the Contract, Vendor specifically acknowledges and agrees that nothing in
that designation shall relieve Vendor of its responsibilities and obligations under the Contract including, but
not limited to,payment of all service fees under any Contract awarded Vendor.
Page 11 of 63
Proposal Forms COMM/SVCS v.05.31.2019
Board®
Cooperative Purchasing
12007 Research Boulevard •Austin,Texas 78759-2439 , PH: 800-695-2919 , FAX: 800-211-5454 • buyboard,com
FELONY CONVICTION DISCLOSURE AND DEBARMENT CERTIFICATION
FELONY CONVICTION DISCLOSURE
Subsection (a) of Section 44.034 of the Texas Education Code (Notification of Criminal History of Contractor)
states: "A person or business entity that enters into a contract with a school district must give advance notice to the district
if the person or an owner or operator has been convicted of a felony. The notice must include a general description of the
conduct resulting in the conviction of a felony."
Section 44.034 further states in Subsection (b): "A school district may terminate a contract with a person or business
entity if the district determines that the person or business entity failed to give notice as required by Subsection (a) or
misrepresented the conduct resulting in the conviction, The district must compensate the person or business entity for
services performed before the termination of the contract."
Please check(16 one of the following:
❑ My company is a publicly-held corporation. (Advance notice requirement does not apply to publicly-held corporation.)
]n My company is not owned or operated by anyone who has been convicted of a felony.
❑ My company is owned/operated by the following individual(s) who has/have been convicted of a felony:
Name of Felon(s):
Details of Conviction(s):
By signature below, I certify that the above information is true, complete and accurate and that I am authorized by my
company to make this certification.
D cMi C.
Co pa Na e
F y�
Sign lure of Authorized Company Official Printed Name
// DEBARMENT CERTIFICATION
Neither my company nor an owner or principal of my company has been debarred, suspended or otherwise made ineligible
for participation in Federal Assistance programs under Executive Order 12549, "Debarment and Suspension,"as described
in the Federal Register and Rules and Regulations. Neither my company nor an owner or principal of my company is
currently listed on the government-wide exclusions in SAM, debarred, suspended, or otherwise excluded by agencies or
declared ineligible under any statutory or regulatory authority. My company agrees to immediately notify the Cooperative
and all Cooperative members with pending purchases or seeking to purchase from my company if my company or an
owner or principal is later listed on the government-wide exclusions in SAM, or is debarred, suspended, or otherwise
excluded by agencies or declared ineligible under any statutory or regulatory authority.
By signature below, I certify that the above is true, complete and accurate and that I am authorized by my company to
make this certification.
1� , ' 1
Company Name
ll
r
V A I �. VA
Sign a o uthorized Company iota Printed Name
Page 12 of 63
Proposal Forms COMM/SVCS v.05.31.2019
wBoard®
Couperative-PuraWasing
12007 Research Boulevard , Austin,Texas 78759-2439 - PH: 800-695-2919 • FAX: 800-211-5451 , tig board.com
RESIDENT/NONRESIDENT CERTIFICATION
Chapter 2252, Subchapter A, of the Texas Government Code establishes certain requirements applicable to proposers who
are not Texas residents. Under the statute, a"resident"proposer is a person whose principal place of business is in Texas,
including a contractor whose ultimate parent company or majority owner has its principal place of business in Texas. A
"nonresident"proposer is a person who is not a Texas resident. Please indicate the status of your company as a"resident"
proposer or a"nonresident"proposer under these definitions.
Please check(y)one of the following:
XI certify that my company is a Resident Proposer.
❑ I certify that my company is a Nonresident Proposer.
If your company is a Nonresident Proposer, you must provide the following information for your resident state (the state in
which your company's principal place of business is located);
Company Name Address
City State Zip Code
A. Does your resident state require a proposer whose principal place of business is in Texas to under-price proposers
whose resident state is the same as yours by a prescribed amount or percentage to receive a comparable contract?
❑ Yes ❑ No
B. What is the prescribed amount or percentage? $ or %
VENDOR EMPLOYMENT CERTIFICATION
Section 44.031(b) of the Texas Education Code establishes certain criteria that a school district must consider when
determining to whom to award a contract. Among the criteria for certain contracts is whether the vendor or the vendor's
ultimate parent or majority owner (i) has its principal place of business in Texas; or (ii) employs at least 500 people in
Texas.
If neither your company nor the ultimate parent company or majority owner has its principal place of business in Texas,
does your company, ultimate parent company, or majority owner employ at least 500 people in Texas?
Please check N) one of the following:
❑ Yes ❑ No
By signature below, I certify that the information in Sections 1 (ResidenVA(onresident Certification) and 2 (Vendor
Employment Certification) above is true, complete and accurate and that I am authorized by my company to make this
certification.
Company N m
9
ignat A orized Company Of cial Printed Name
Page 13 of 63
Proposal Forms COMM/SVCS v.05.31.2019
Board
Cooperative Purchasing
12007 Research Boulevard •Austin,Texas 78759-2439 • PH: 800-695-2919 • FAX: 800-211-5454 • buvboard.com
NO ISRAEL BOYCOTT CERTIFICATION
Effective September 1, 2017, as amended effective May 7, 2019 (H.B. 793), a Texas governmental entity may not enter
into a contract with a value of $100,000 or more that is to be paid wholly or partly from public funds with a company
(excluding a sole proprietorship) that has 10 or more full-time employees for goods or services unless the contract contains
a written verification from the company that it: (1) does not boycott Israel; and (2) will not boycott Israel during the term
of the contract. (TEX.Gov'T CODE Ch. 2270), Accordingly, this certification form is included to the extent required by law.
"Boycott Israel" means refusing to deal with, terminating business activities with, or otherwise taking any action that is
intended to penalize, inflict economic harm on, or limit commercial relations specifically with Israel, or with a person or
entity doing business in Israel or in an Israeli-controlled territory, but does not include an action made for ordinary business
purposes. TEx. GOv'T CODE§808.001(1).
By signature below, I certify and verify that Vendor does not boycott Israel and will not boycott Israel during the term of
any contract awarded under this Proposal Invitation, that this certification is true, complete and accurate, and that I am
authorized by my company to make this certification.
Company Name
Sign re of Authorized Company Official Printed Name
Note: If Vendor does not wish to make this certification,return the blank form in lieu of a completed
certifica tion.
NO EXCLUDED NATION OR FOREIGN TERRORIST ORGANIZATION CERTIFICATION
Effective September 1, 2017, Chapter 2252 of the Texas Government Code provides that a Texas governmental entity may
not enter into a contract with a company engaged in active business operations with Sudan, Iran, or a foreign terrorist
organization —specifically, any company identified on a list prepared and maintained by the Texas Comptroller under Texas
Government Code §§806.051, 807.051, or 2252.153. (A company that the U.S. Government affirmatively declares to be
excluded from its federal sanctions regime relating to Sudan, Iran, or any federal sanctions regime relating to a foreign
terrorist organization is not subject to the contract prohibition.)
By signature below, I certify and verify that Vendor is not on the Texas Comptroller's list identified above; that this
certification is true, complete and accurate; and that I am authorized by my company to make this certification.
6bie, �.4 Qk�:l
Company Nanle
Kg n re o Authorized Company Official Printed Name
Page 14 of 63
Proposal Forms COMM/SVCS v,05.31.2019
Board
Cooperative Purchasing
12007 Research Boulevard • Austin,Texas 78759-2439 • PH: 800-695-2919 ' FAX: 800-211-5454 ' buyboard.com
HISTORICALLY UNDERUTILIZED BUSYNESS CERTIFICATION
A proposer that has been certified as a Historically Underutilized Business (also known as a Minority/Women Business
Enterprise or "MWBE" and all referred to in this form as a "HUB') is encouraged to indicate its HUB certification status
when responding to this Proposal Invitation. The electronic catalogs will indicate HUB certifications for vendors that
properly indicate and document their HUB certification on this form.
Please check(-V) all that apply:
❑ I certify that my company has been certified as a HUB in the following categories:
❑ Minority Owned Business
❑ Women Owned Business
❑ Service-Disabled Veteran Owned Business (veteran defined by 38 U.S.C. §101(2), who has a
service-connected disability as defined by 38 U.S.C. § 101(16), and who has a disability rating
of 20% or more as determined by the U. S. Department of Veterans Affairs or Department of
Defense)
Certification Number:
Dame of Certifying Agency:
My company has NOT been certified as a HUB.
By signature below, I certify that the above is true, complete and accurate and that I am authorized by my
company to make this certification.
b6bie S
Companny Name
\fo V
Printed Name
Signs re of Authorized Company Official
Page 15 of 63
Proposal Forms CQMM/SVCS v.05.31,2019
PVBoard
C00perativePurchasing
12007 Research Boulevard • Austin,Texas 78759-2439 , PH: 800-695-2919 ' FAX: 800-211-5454 • buyboard.com
CONSTRUCTION-RELATED GOODS AND SERVICES AFFIRMATION
A contract awarded under this Proposal Invitation covers only the specific goods and services awarded by the BuyBoard. As
explained in the BuyBoard Procurement and Construction Related Goods and Services Advisory for Texas Members
("Advisory', Texas law prohibits the procurement of architecture or engineering services through a
purchasing cooperative. This BuyBoard contract does not include such services. Architecture or engineering
services must be procured by a Cooperative member separately, in accordance with the Professional
Services Procurement Act (Chapter 2254 of the Texas Government Code) and other applicable law and local
policy.
The Advisory, available at buyboard.com/Vendor/Resources.aspx, provides an overview of certain legal requirements that
are potentially relevant to a Cooperative member's procurement of construction or construction-related goods and services,
including those for projects that may involve or require architecture, engineering or independent testing services. A copy
of the Advisory can also be provided upon request,
By signature below, the undersigned affirms that Proposer has obtained a copy of the Advisory, has read and understands
the Advisory, and is authorized by Proposer to make this affirmation. If Proposer sells construction-related goods or
services to a Cooperative member under a BuyBoard contract awarded under this Proposal Invitation, Proposer will comply
with the Advisory and applicable legal requirements, make a good faith effort to make its Cooperative member customers
or potential Cooperative member customers aware of such requirements, and provide a Cooperative member with a copy
of the Advisory before executing a Member Construction Contract with the member or accepting the member's purchase
order for construction-related goods or services, whichever comes first.
Compan Na e
I
S� ture of Authorized Company Official Printed Name
V5 f
Dtite
Page 16 of 63
Proposal Forms COMM/SVCS v.05.31.2019
Board
Cooperative Purchasing
12007 Research Boulevard • Austin,Texas 78759-2439 • PH: 800-695-2919 ' FAX: 800-211-5454 - buyboard.com
DEVIATION AND COMPLIANCE
If your company intends to deviate from the General Terms and Conditions, Proposal Specifications or other requirements
associated with this Proposal Invitation, you MUST list all such deviations on this form, and provide complete and detailed
information regarding the deviations on this form or an attachment to this form. The Cooperative will consider any
deviations in its contract award decision, and reserves the right to accept or reject a proposal based upon any submitted
deviation.
In the absence of any deviation identified and described in accordance with the above, your company must fully comply
with the General Terms and Conditions, Proposal Specifications and all other requirements associated with this Proposal
Invitation if awarded a contract under this Proposal Invitation. A deviation will not be effective unless accepted by the
Cooperative. The Cooperative may, in its sole discretion, seek clarification from and/or communicate with Proposer(s)
regarding any submitted deviation, consistent with general procurement principles of fair competition. The Cooperative
reserves the right to accept or reject a proposal based upon any submitted deviation.
Please check(d) one of the following:
NO; Deviations
❑ Yes; Deviations
List and fully explain any deviations you are submitting:
PLEASE PROVIDE THE FOLLOWING INFORMATION:
l
1. Shipping Via: UICOmmon Carrier [e Company Truck ❑ Prepaid and Add to Invoice ❑ Other:
2. Payment Terms: VNet 30 days ❑ 1% in 10/Net 30 days ❑ Other:
I
i
3. Number of Days for Delivery: 6—J I ARO
4. Vendor Reference/Quote Number:' R� _p
S. State your return policy: r[�'i S ct or 1<n arru VI]attefs
��5
6. Are electronic payments acceptable? 4Y,Yes El No
7. Are credit card payments acceptable? E9 es ❑ No
Company Name
i
Sign re of Authorized Company Official Pr nted Name
Page 17 of 63
Proposal Forms COMMISVCS v.05.31.2019
PFBoard
CapperaUveftrchasing
12007 Research Boulevard • Austin,Texas 78759-2439 • PH: 800-695-2919 • FAX: 800-211-5454• buvboard.com
LOCATION AUTHORIZED SELLER LISTINGS
If you have more than one location/authorized seller that will service a contract awarded under this Proposal Invitation,
please list each location/authorized seller below. If additional sheets are required, please duplicate this form as necessary.
NOTE: Awarded Vendors shall remain responsible for all aspects of the Contract, including processing of Purchase Orders,
and shall be responsible for the performance of all locations and authorized sellers under and in accordance with the
Contract. If you are a product manufacturer and wish to designate Designated Dealers as defined in the General Terms
and Conditions to receive Cooperative member Purchase Orders on your behalf, you must complete the Manufactuurr rr
Designated Dealer form. G��""✓
Company Name
Address
City State Zip
Phone Number Fax Number
Contact Person
Company Name
Address
City State zip
Phone Number Fax Number
Contact Person
Page 18 of 63
Proposal Forras COMMISKS v.05.31,2019
DuBoard
CapperativePurchashig
12007 Research Boulevard • Austin,Texas 78759-2439 � PH: 800-695-2919 • FAX: 800-211-5454 • buyboard.com
MANUFACTURER DEALER DESIGNATION
If Vendor is a manufacturer that sells products through a dealer network and wishes to designate a dealer or multiple
dealers ("Designated Dealers') to receive Cooperative member Purchase Orders on Vendor's behalf, you must complete
this form for each dealer you wish to designate.
Regardless of any Designated Dealers submitted by Vendor, Vendor specifically agrees and acknowledges that any such
designations are for Vendor's convenience only and shall not, if Vendor is awarded a Contract, relieve Vendor of any
obligations under the Contract, including payment of Cooperative service fees on all Purchase Orders submitted to Vendor
or any Designated Dealer. In accordance with the General Terms and Conditions, an awarded Vendor shall remain
responsible and liable for all of its obligations under the Contract and the performance of both Vendor and any of Vendor's
Designated Dealers under and in accordance with the Contract and remain subject to all remedies for default thereunder,
including, but not limited to suspension and termination of Vendor's Contract for nonpayment of service fees.
If awarded, Vendor authorizes the Cooperative, in its sole discretion, to list any Vendor Designated Dealers in the BuyBoard
system and to receive Purchase Orders directly from Cooperative members on behalf of Vendor. To the extent a Vendor
with Designated Dealers receives a Purchase Order directly, it shall be the responsibility of Vendor to appropriately process
such Purchase Order in accordance with the Contract, including but not limited to timely forwarding such Purchase Order to
a Designated Dealer for processing.
The Cooperative reserves the right, in its sole discretion, to refuse addition of, or request removal of, any Designated
Dealer, and Vendor agrees to immediately require such Designated Dealer to cease accepting Purchase Orders or otherwise
acting on Vendor's behalf under the Contract. Further, the Cooperative's administrator shall be authorized to remove or
suspend any or all Designated Dealers from the BuyBoard at any time in its sole discretion.
If you wish to designate a dealer to service a contract awarded under this Proposal Invitation, please list the Designated
Dealer below and have this form signed by an official of your company authorized to make such designation. If you wish
to designate multiple dealers, please duplicate this form as necessary.
Designated Dealer Name
Designated Dealer Address
City State zip
Phone Number Fax Number
Email address Designated Dealer Tax ID Number* (*attach W-9)
Designated Dealer Contact Person 1
c, i '
Your Company Name na o Au horized Company fficial
Page 19 of 63
Proposal Forms COMM/SVCS v.05.31.2019
P 0 AD
Board®
Cooperative Purchasing
12007 Research Boulevard •Austin,Texas 78759-2439 • PH: 800-695-2919 ' FAX: 800-211-5454 ' buyboard.com
L
TEXAS REGIONAL SERVICE DESIGNATION
The Cooperative (referred to as"Texas Cooperative"in this form and in the State Service Designation form) offers vendors
the opportunity to service its members throughout the entire State of Texas. If you do not plan to service all Texas
Cooperative members statewide, you must indicate the specific regions you will service on this form. If you propose to
serve different regions for different products or services included in your proposal,you must complete and
submit a separate Texas Regional Service Designation form for each group of products and clearly indicate
the products or services to which the designation applies in the space provided at the end of this form. By
designating a region or regions, you are certifying that you are authorized and willing to provide the
proposed products and services in those regions Designating regions in which you are either unable or
unwilling to provide the specified products and services shall be grounds for either rejection of your
proposal or,if awarded, termination of your Contract. Additionally, if you do not plan to service Texas Cooperative
members(Le., if you will service only states other than Texas), you must so indicate on this form.
Regional Education Service Centers ❑ I will service Texas
— - Cooperative mipmbers
statewide.
1 ��� ❑ I will not service Texas
x Cooperative members ,
a-.-
statewide, I will only
service members in the
regions checked below:
law •r q �F C
Region Headquarters,
y 1 Edinburg
2 Corpus Christi
3 Victoria
19 Yc Mr 4 Houston
r.m Y" 5 Beaumont
6 Huntsville
wl7 Kilgore
8 Mount Pleasant
v v 9 Wichita Falls
� ? 10 Richardson
" r 11 Fort Worth
�.,� �= • d 12 Waco
13 Austin
14 Abilene
15 San Angelo
16 Amarillo
17 Lubbock
Lam' 18 Midland
Company Name ❑ 19 El Paso
20 San Antonio
Sign re o tithorized 0I icial
k it
`.4 _ ❑ I will not service members li
Printed Name of the Texas Cooperative.
Page 20 of 63
Proposal Forms COMM/SVCS v,05.31.2019
I
PFBoard®
CouperativePurchitsing
12007 Research Boulevard • Austin,Texas 78759-2439 - PH: 800-695-2919 • FAX: 800-211-5454•huyboard.com
STATE SERVICE DESIGNATION
The Cooperative offers vendors the opportunity to service other governmental entities in the United States, including
intergovernmental purchasing cooperatives such as the National Purchasing Cooperative BuyBoard. You must complete
this form if you plan to service the entire United States, or will service only the specific states indicated. (Note:If you plan
to service Texas Cooperative members, be sure that you complete the Texas Regional Service Designation form.)
If you serve different states for different products or services included in your proposal, you must complete
and submit a separate State Service Designation form for each group of products and clearly indicate the
products or services to which the designation applies in the space provided at the end of this form. By
designating a state or states,you are certifying that you are authorized and willing to provide the proposed
products and services in those states. Designating states in which you are either unable or unwilling to
provide the specified products and services shall be grounds for either rejection of your proposal or, if
awarded, termination of your Contract.
Please check all that apply:
❑ I will service all states in the United States.
13
/ I will not service all states in the United States. I will service only the states checked below:
❑ Alabama
❑ Alaska ❑ Nebraska
❑ Arizona ❑ Nevada
❑ Arkansas ❑ New Hampshire
❑ California (Public Contract Code 20118 & 20652) ❑ New Jersey
❑ Colorado ❑ New Mexico
❑ Connecticut ❑ New York
❑ Delaware ❑ North Carolina
❑ District of Columbia ❑ North Dakota
❑ Florida ❑ Ohio
❑ Georgia ❑ Oklahoma
❑ Hawaii ❑ Oregon
❑ Idaho ❑ Pennsylvania
❑ Illinois ❑ Rhode Island
❑ Indiana ❑ South Carolina
❑ Iowa ❑ South Dakota
❑ Kansas ❑Tennessee
El Kentucky exas
❑ Louisiana ❑ Utah
❑ Maine ❑ Vermont
❑ Maryland ❑ Virginia
❑ Massachusetts ❑ Washington
❑ Michigan ❑ West Virginia
❑ Minnesota ❑ Wisconsin
❑ Mississippi ❑ Wyoming
❑ Missouri
❑ Montana
Page 22 of 63
Proposal Forms COMMJSVCS v.05.31.2019
Board
Cooperative Purchasing
12007 Research Boulevard • Austin,Texas 78759-2439 • PH: 800-695-2919 • FAX: 800-211-5454 • buyboard.com
This form will be used to ensure that you can service other governmental entities throughout the United States as
indicated. Your signature below confirms that you understand your service commitments during the term of a
contract awarded under this proposal.
D die LL
Comp ny Nam
-Signature of Authorized Company Official Printed Name
If this State Service Designation form applies to only one or some of the products and services proposed by Vendor,
list the products and services to which this form applies here:
Page 23 of 63
Proposal Forms COMM/SVCS v.05.31.2019
PFBoard®
Cooperativa Purchasing
12C07 Research Boulevard , Austin,Texas 78759-2439 • PH: 800-695-2919 , FAX: 800-211-5454 • buyboard,com
NATIONAL PURCHASING COOPERATE� V/ENDOR AWARD AGREE imrLNT
In accordance with the Terms and Conditions associated with this Proposal Invitation, a contract awarded under this
Proposal Invitation may be "piggy-backed" by another governmental entity. The National Purchasing Cooperative is an
intergovernmental purchasing cooperative formed by certain school districts outside of Texas to serve its members
throughout the United States. If you agree to be considered for a piggy-back award by the National Purchasing
Cooperative, you agree to the following terms and agree to serve National Purchasing Cooperative members in the states
you have indicated on the State Service Designation form, in your Proposal.
By signing this form, Proposer(referred to in this Agreement as"Vendor") agrees as follows:
1. Vendor acknowledges that if The Local Government Purchasing Cooperative ("Texas Cooperative'o awards Vendor a
contract under this Proposal Invitation ("Underlying Award'% the National Purchasing Cooperative ("National Cooperative")
may - but is not required to - "piggy-back"on or re-award all or a portion of that Underlying Award ("Piggy-Back Award').
By signing this National Cooperative Vendor Award Agreement ("Agreement'), Vendor accepts and agrees to be bound by
any such Piggy-Back Award as provided for herein.
2. In the event National Cooperative awards Vendor a Piggy-Back Award, the National Cooperative Administrator
("BuyBoard Administrator's will notify Vendor in writing of such Piggy-Back Award, which award shall commence on the
effective date stated in the Notice and end on the expiration date of the Underlying Award, subject to annual renewals as
authorized in writing by the BuyBoard Administrator. Vendor agrees that no further signature or other action is required of
Vendor in order for the Piggy-Back Award and this Agreement to be binding upon Vendor. Vendor further agrees that no
interlineations or changes to this Agreement by Vendor will be binding on National Cooperative, unless such changes are
agreed to by its BuyBoard Administrator in writing.
3. Vendor agrees that it shall offer its goods and services to National Cooperative members at the same unit pricing and
same general terms and conditions, subject to applicable state laws in the state of purchase, as required by the Underlying
Award. However, nothing in this Agreement prevents Vendor from offering National Cooperative members better (i.e.,
lower) competitive pricing and more favorable terms and conditions than those in the Underlying Award.
4. Vendor hereby agrees and confirms that it will serve those states it has designated on the State Service Designation
Form of this Proposal Invitation. Any changes to the states designated on the State Service Designation Form must be
approved in writing by the BuyBoard Administrator.
S. Vendor agrees to pay National Cooperative the service fee provided for in the Underlying Award based on the amount of
purchases generated from National Cooperative members through the Piggy-Back Award. Vendor shall remit payment to
National Cooperative on such schedule as it specifies (which shall not be more often than monthly). Further, upon
request, Vendor shall provide National Cooperative with copies of all purchase orders generated from National Cooperative
members for purposes of reviewing and verifying purchase activity. Vendor further agrees that National Cooperative shall
have the right, upon reasonable written notice, to review Vendor's records pertaining to purchases made by National
Cooperative members in order to verify the accuracy of service fees.
I
f. Vendor agrees that the Underlying Award, including its General Terms and Conditions, are adopted by reference to the
fullest extent such provisions can reasonably apply to the post-proposa I/contract award phase. The rights and
responsibilities that would ordinarily inure to the Texas Cooperative pursuant to the Underlying Award shall inure to
National Cooperative; and, conversely, the rights and responsibilities that would ordinarily inure to Vendor in the Underlying
Award shall inure to Vendor in this Agreement. Vendor recognizes and agrees that Vendor and National Cooperative are the
only parties to this Agreement, and that nothing in this Agreement has application to other third parties, including the
Texas Cooperative. in the event of conflict between this Agreement and the terms of the Underlying Award, the terms of
this Agreement shall control, and then only to the extent necessary to reconcile the conflict.
Proposal Forms COMMISVC5 v.05,31.2019
Page 24 of 63
I
Board
Cooperative Purchasing
12007 Research Boulevard ,Austin,Texas 78759-2439 • PH: 800-695-2919 1 FAX: 800-211-5454• boboard,com
7. This Agreement shall be governed and construed in accordance with the laws of the State of Rhode Island and venue
for any dispute shall lie in the federal district court of Alexandria,Virginia.
8. Vendor acknowledges and agrees that the award of a Piggy-Back Award is within the sole discretion of National
Cooperative, and that this Agreement does not take effect unless and until National Cooperative awards Vendor a Piggy-
Back Award and the BuyBoard Administrator notifies Vendor in writing of such Piggy--Back Award as provided for herein.
WHEREFORE, by signing below Vendor agrees to the foregoing and warrants that it has the authority to enter into this
Agreement.
0
ame of Vendor Proposal Invitation Number
Va IIAA B� , A
Sign of Authorized Company Official Printed Name of Authoriz Company Official
Date
Proposal Forms COMM/SVCS v.05.31.2019
Page 25 of 63
Board
Cooperative Purchasing
12007 Research Boulevard • Austin,Texas 78759-2439 • PH: 800-695-2919 • FAX: 800-211-5454 . buyboard,com
FEDERAL AND STATE/PURCHASING COOPERATIVE EXPERIENCE
The Cooperative strives to provide its members with the best services and products at the best prices available from
vendors with the technical resources and ability to serve Cooperative members. Please respond to the following questions.
1. Provide the dollar value of sales to or through purchasing cooperatives at or based on an established catalog or
market price during the previous 12-month period or the last fiscal year: $ U . U0 . (The period of the 12
month period is III jo I? / . In the event that a dollar value is not an appropriate measure of the sales,
provide and describe your own measure of the sales of the item(s).
2. By submitting a proposal, you agree that, based on your written discounting policies, the discounts you offer the
Cooperative are equal to or better than the best price you offer other purchasing cooperatives for the same items
under equivalent circumstances.
3. Provide the information requested below for other purchasing cooperatives for which Proposer currently serves, or in
the past has served, as an awarded vendor. Rows should be added to accommodate as many purchasing
cooperatives as required.
FORMERCURRENT D•. AWARDED
VENDOR?PURCHASING • •D
GROUPVENDOR ••
1. Federal General Services Administration
2. T-PASS (State of Texas)
3. OMNIA Partners
4. Sourcewell (N]PA)
S. E&I Cooperative }
6. Houston-Galveston Area Council (HGAQ
7. Choice Partners 1�
S. The Interlocal Purchasing System (TIPS)
9. Other
I/MY COMPANY DOES NOT CURRENTLY HAVE ANY OF THE ABOVE OR SIMILAR TYPE CONTRACTS.
CURRENT BUYBOARD VENDORS
If you are a current BuyBoard vendor in the same contract category as proposed in this Proposal Invitation, indicate the
discount for your current BuyBoard contract and the proposed discount in this Proposal. Explain any difference between
your current and proposed discounts.
Current Discount(%): Proposed Discount (%):
Explanation:
Proposal Forms COMM/SVCS v.05.31.2019
Page 26 of 63
Board
Cooperative Purchasing
12007 Research Boulevard ' Austin,Texas 78759-2439 • PH: 800-695-2919 ' FAX: 800-211-5454 ' buyboard.com
By signature below, I certify that the above is true, complete and accurate and that I am authorized by my company to
make this certification. 1
Company Nam
Si
fiaure of Authorized Company Official printed Name
Proposal Forms COMM/SVCs v.05.31.2019
Page 27 of 63
DwCouperativePurchasing
12007 Research Boulevard • Austin,Texas 78759-2439 • PH: 800-695-2919 • FAX: 800-211-5454 • buyboard.com
GOVERNMENTAL REFERENCES
For your Proposal to be considered, you must supply a minimum of five (5) individual governmental entity references. The
Cooperative may contact any and all references provided as part of the Proposal evaluation. Provide the information
requested below, including the existing price/discounts you offer each customer. The Cooperative may determine whether
prices/discounts are fair and reasonable by comparing prices/discounts stated in your Proposal with the prices/discounts
you offer other governmental customers. Attach additional pages if necessary.
Quantity/
Entily Name Contact Phone# Email Address Discount Volume
n v4q —//QO�y
2. �_ ocd Ch"& S( �Y.�Q�iP i V1 dswd c . t`X�� Lp rr n,-tua i
3. �I �f(f1 (yq t�1'�iiQrRl d ln�fati q 1 R- E.ttg— l la'7 0 �,i+)afeLrylp InAI jertQu±.+". -
e J, � - 9 0 b 0 I�c.%0L%R �-`R i��J[P�, u=-fir ,a�✓ � 'r"�
f g- r Yi es.
Do you ever modify your written policies or standard governm ntal sales practices as identified in the above chart to give
better discounts (lower prices) than indicated? YES ❑ NO If YES, please explain:
By signature below, I certify that the above is true and correct and that I am authorized by my company to make this
certification.
Company Na
gnature of Authorized Company Official
\Um' Ski )j
Printed Name
I
Proposal Forms COMM/SVCS v,05,31,2019
Page 28 of 63 I
i
Board
DuCapperative Purchasing
12007 Research Boulevard • Austin,Texas 78759-2439 • PH: 800-695-2919 • FAX: 800-211-5454 • buyboard.com
MARKETING STRATEGY
For your Proposal to be considered, you must submit the Marketing Strategy you will use if the Cooperative accepts all or
part of your Proposal (Example: Explain how your company will initially inform Cooperative members of your BuyBoard
contract, and how you will continue to support the BuyBoard for the duration of the contract period)
Attach additional pages if necessary.
A-Avtlyil-<'� -�O'oi
-C a -
M
i LLC'..
Company Name
JS' nat�'uj're of Authorized Company Official
VCA� ol-_ )��' I -VIA
Printed Name
Proposal Forms COmm/Svcs v,os,31.2019
Page 29 of 63
.PD Bnard10
wCouperative Purchasing
12007 Research Boulevard ' Austin,Texas 78759-2439 • PH: 800-695-2919 , FAX: 800-211-5454 • buyboard.com
CONFIDENTIAL PROPRIETARY INFORMATION
A. Public Disclosure Laves
All Proposals, forms, documentation, or other materials submitted by Vendor to the Cooperative in response to this
Proposal Invitation, including catalogs and pricelists, may be subject to the disclosure requirements of the Texas Public
Information Act (Texas Government Code chapter 552.001, et seq.) or similar disclosure law. Proposer must clearly
identify on this form any information in its Proposal (including forms, documentation, or other materials submitted with the
Proposal) that Proposer considers proprietary or confidential. If Proposer fails to properly identify the information, the
Cooperative shall have no obligation to notify Vendor or seek protection of such information from public disclosure should a
member of the public or other third parry request access to the information under the Texas Public Information Act or
similar disclosure law. Proposer will be notified of any third party request for information in a Proposal that Proposer has
identified in this form as proprietary or confidential.
Does your Proposal (including forms, documentation, or other materials submitted with the Proposal) contain information
which Vendor considers proprietary or confidential?
Please eck one of the followin :
NO, I certify that none of the information included with this Proposal is considered confidential or proprietary.
YES, I certify that this Proposal contains information considered confidential or proprietary and all such information is
specifically identified on this form.
If you responded"YES", you must identify below the specific information you consider confidential or proprietary. List each
page number, form number, or other information sufficient to make the information readily identifiable. The Cooperative
and its Administrator will not be responsible for a Proposer's failure to clearly identify information considered confidential or
proprietary. Further, by submitting a Proposal, Proposer acknowledges that the Cooperative and its Administrator will
disclose information when required by law, even if such information has been identified herein as information the vendor
considers confidential or proprietary.
Confidential/ Proprietary Information:
I
(Attach additional sheets if needed.)
Proposal Forms COMM/SVCS v,05.31.2019
Page 30 of 63
DwBoarc�p
GuoperativeParchasing
12007 Research Boulevard • Austin,Texas 78759-2439 , PH; 800-695-2919 • FAX; 800-211-5454 • buyboard.com
B. Copyright Information
Does your Proposal (including forms, documentation, or other materials submitted with the Proposal) contain copyright
information?
Please check(A one of the following:
NO, Proposal(including forms,documentation, or other materials submitted with the Proposal)does not
contain copyright information.
❑ YES, Proposal(including forms,documentation, or other materials submitted with the Proposal)does
contain copyright information.
If you responded `YES", identify below the specific documents or pages containing copyright information.
Copyright Information:
(Attach additional sheets if needed.)
C.Consent to Release Confidential I Pro rieta Copyright Information to BuyBoard Members
BuyBoard members (Cooperative and nonprofit members) seeking to make purchases through the BuyBoard may wish to
view information included in the Proposals of awarded Vendors. If you identified information on this form as confidential,
proprietary, or subject to copyright, and you are awarded a BuyBoard contract, your acceptance of the BuyBoard contract
award constitutes your consent to the disclosure of such information to BuyBoard members, including posting of such
information on the secure BuyBoard website for members. Note: Neither the Cooperative nor its Administrator will be
responsible for the use or distribution of information by BuyBoard members or any other party.
D.Consent to Release Proposal Tabulation
Notwithstanding anything in this Confidential/Proprietary Information form to the contrary, by submitting a Proposal,
Vendor consents and agrees that, upon Contract award, the Cooperative may publically release, Including posting on the
public BuyBoard website, a copy of the proposal tabulation for the Contract including Vendor name; proposed
catalog/pricel ist name(s); proposed percentage discount(s), hourly labor rate(s), or other specified pricing; and Vendor
award or non-award information.
By signature below, I certify that the information in this form is true, complete, and accurate and that I am authorized by
my company to make this certification and all consents and agreements contained herein.
1 LL
Company Name
e'4�a'—a
Si ature of Authorized Company Official
Printed Name
Date
Proposal Forms COMMISVCS v.05.31.2019
Page 31 of 63
Board®
Cooperative Purchasing
12007 Research Boulevard • Austin,Texas 78759-2439 , PH: 800-695-2919 • FAX: 800-211-5454 • buyboard.com
VENDOR BusmESS NAME
By submitting a Proposal, Proposer is seeking to enter into a legal contract with the Cooperative. As such, a Proposer must
be an individual or legal business entity capable of entering into a binding contract. Proposers, must completely and
accurately provide the information requested below or your Proposal may be deemed non-responsive.
� i `>Name of Proposing Company: �� 0( LLC•
(List the e al name of the company seeking to contract with the Cooperatl . Do NOT fistan assumed name,dba,aka,etc,here. Such information may
be provided below. If you are submitting a joint proposal with another entity to provide the same proposed goods or services, each submitting entity
should complete a separate vendor Information form. Separately operating legal business entities, even if affiliated entities, which propose to provide
goods or services separately must submit their own Proposals)
Please check(3n one of the following:
Type of Business:
Individual/Sole Proprietor
Corporation
Limited Liability Company �
Partnership
Other If other, identify
State of Incorporation (if applicable): �� h
Federal Employer Identification Number: Y J `Q 5"I V
(Vendor must include a completed IRS W-g form with their proposal)
i
i
i
List the Name(s) by which Vendor, if awarded, wishes to be identified on the BuyBoard: (Note: rf different than the Name of
Proposing Company listed above, only valid trade names(dba, aka, etc.)of the Proposing Company may be used and a copy of your Assumed Name
Certificate(s),ifapplicable,must be attached.)
tv)wkt 14 An io S4 �.L.0
Proposal Forms COMM/SVCS u05.31.2019
Page 32 of 63
Form W 9 Request for Taxpayer Give Form to the
(Rev.December 2014) requester. Do not
Department of the Treasury identification Number and Certification send to the tRS,
Internal Revenue Service
1 Name(as shown on your income tax return).Name Is required on this line;do not leave this line blank.
Dobie Supply LLC
N 2 l3usiness Homo/disregarded entity name,if different from above -
3 Check appropriate box for federal tax classification;check only one of the following seven boxes: 4 Exemptions(codes apply only to
° ❑Individual/sole proprietor p ❑ C Corporation ❑S Corporation ❑ Partnership ❑Trust/estate certain entities,not Individuals;see r#etor or
Q o single-mernbor LLG Instructions on page 3);
❑✓ Llmited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=partnership)0, P Exempt payee code(if any)
a Note.For a single-member LLC that is disregarded,no not check LLC;check the appropriate box in the line above lot Exemption from FATCA reporting
N the tax classification of the single-member owner. code(If any)
c
p n _❑Other(see Instructions) tAq IWoaccanN—Jaminndoutside M.U&J
5 Address(number,street,and apt.ar suite no.) Requester's name and address(op€Ional)
3809 S.2nd Street,#D-200
n�) 6 City,state,and'ZIP code —
rn Austin, TX 78704
7 List account number(s)here(optional) a
Taxpayer Identification plumber Ipl}
Enter your TIN in the appropriate box.The TIN provided must match the name given on line 1 to avoid social security number
backup wiihliolding,For individuals,this is generally your social security number(SSN).However,for a
resident alien,safe proprietor,or disregarded entity,see the Part I Instructions on page 3.For other _see Mow to get a
e a number, ID _I]=
entities,It is your employer Idenlificatlon number(EfN).If you do not hav ,
TIN nn page 3, Or
Note.If the account is in more than one name,see the Instructions for line 1 and the chart on page 4 for Employer Identification number
guidelines on whose number to enter.
Certification
Under penalties of perjury,I certify that:
1. The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be Issued to me);and
2. 1 am not subject to backup withholding because;(a)I am exempt from backup withholding,or(b)I have not been notified by the Internal Revenue
Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified me that I am
no longer subject to backup withholding;and -
3, 1 am a U.S,citizen or other U.S.person(defined below);and
4.The FATCA code(s)entered on this form(if any)Indicating that f am exempt from FATCA reporting is correct.
Certification instructions.You must cross out item 2 above If you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return.For real estate transactions,ilem 2 does not apply,For mortgage
interest paid,acquisition or abandonment of secured property,cancellation of debt,contributions to an individual retirement arrangement(IRA),and
generally,payments other than Interest and dividends,you are not required to sign the certification,but you must provide your correct TIN.See the
Instructions on page 3.
S11,n Signature of J
Here U.S.person
► oat.0 �l 1 f j
General Instructions `Form 1098(home mortgage Interest),10911-E(student loan Interest),1008-T
(tuition)
Section references are to the internal Revenue Code unless otherwise noted. •Form 1099-C(canceled debt)
Future developments.Information about developments affecting Form W-9(such .Form 1099-A(acquisition or abandonment of scoured property)
as legislation enacted after we release it)is at www.irs.gov/hv9.
Use Form W-9 only if you are a U.S.person(including a resident alien),to
Purpose of Form provide your correct TIN.
An individual or entity(Form W-9 requester)who is required to file an information If you do not return Form W-9 to the requosfer with a TIN,you might be subject
return with the IRS must obtain your correct taxpayer identification number(TIN) to backup withholding.See What Is backup withholding?on page 2.
which may be your social security number(SSN),individual taxpayer Identification By signing the filled-out form,you:
number(ITIN),adoption taxpayer Idenreport
o€Ian Information
Homier(ATINreturn or employer 1.Certify that the TIN you are giving is correct(or you are wailing for a number
Identification number(EIN),to report on an Information return the amount paid to to be issued),
you,or other amount reportable on an information return.Examples of Information
returns include,but are not limited to,the following: 2.Certify that you are not subject to backup withholdfng,or
•Form 1099-€NT(Interest earned or paid) 3.Claim exemption from backup withholding It you are a U.S.exempt payee.If
•Form 1099-HIV(dividends,including those from stocks or mutual funds) applicable,you are also certifying that as a U.S.person,your allocable share of
any partnership Income from a U.S,trade or buslness is not subject to the
•Form 1099-MISC(various typos of income,prizes,awards,or gross proceeds) withholding tax on foreign partners'share of effectively connected income,and
•Form 1099-8(stock or mutual fund sales and certain other transactions by 4.Certify that FATGA code(s)entered on this form(If any)indicating that you aro
brokers) exempt from the FATGA reporting,Is correct.See What is FATCA reporting?on
•Form 1099-S(proceeds from real estate transactions) page 2 for furlher information.
•Form 1099-K(merchant card and third party network transactions)
Gat.No.10231X Form W-9(Rev.12-2014)
PFBoard®
Cooperative Purchasing
12007 Research Boulevard , Austin,Texas 78759-2439 • PH: 800-695-2919 , FAX: 800-211-5454 • buyboard.com
12. General Compliance and Cooperation with Cooperative Members:
In addition to the foregoing specific requirements, Vendor agrees, in accepting any Purchase Order from a Cooperative
member, it shall make a good faith effort to work with Cooperative members to provide such information and to satisfy II
such requirements as may apply to a particular Cooperative member purchase or purchases including, but not limited to,
applicable recordkeeping and record retention requirements.
Vendor Certification:
YES, I agree or
Vendor Certification Item No. NO I do NOT a ree Initiai
1. Vendor Violation or Breach of Contract Terms
2. Termination for Cause or Convenience
3. Equal Employment Opportunity 1 �„
4. Davis-Bacon Act A�
5. Contract Work Hours and Safety Standards Act � V
6. Right to Inventions Made Under a Contract or Agreement e
7. Clean Air Act and Federal Water Pollution Control Act
S. Debarment and Suspension
9. Byrd Anti-Lobbying Amendment `
10. Procurement of Recovered Materials
11. Profit as a Separate Element of Price
12. General Compliance and Cooperation with Cooperative Members
By signature below, I certify that the information in this form is true, complete, and accurate and that I am authorized by
my company to make this certification and all consents and agreements contained herein.
Company Name
ig ture of Authorized Company fficial
Printed Name
Proposal Forms Comm/Svcs v.05.31.2619
Page 36 of 63
PVBoard
Cnaparative Purchasiny
12007 Research Boulevard • Austin,Texas 78759-2439 • PH: 800-695-2919 . FAX: 800-211-5454 • buyboard,com
PROPOSAL INVITATION QUESTIONNAIRE
The Cooperative will use your responses to the questions below in evaluating your Proposal and technical and financial
resources to provide the goods and perform the services ("Work') under the BuyBoard contract contemplated by this
Proposal Invitation ("Contract'o. Proposers must fully answer each question, numbering your responses to correspond to
the questions/numbers below. Proposers must complete below or attach your responses to this questionnaire, sign where
indicated below, and submit the signed questionnaire and your responses to all questions in one document with your
Proposal. You must submit the signed questionnaire and responses with your Proposal or the Proposal will
not he considered.
1. List the number of years Proposer has been in business and former business names (if applicable). Note whether your
company is currently for sale or involved in any transaction that would significantly alter its business or result in
acquisition by another entity.
~e- S
2. Describe the resources Proposer has to manage staff and successfully perform the Work contemplated under this
Contract. State the number and summarize the experience of company personnel who may be utilized for the Work,
including those who will be available to Cooperative members for assistance with project development, technical issues,
and product selection for Work associated with this Contract.
SA7aw cf WOE Vq'aV--e-'kQM5(f aKJ- Ua.�'CA �w S�WaA-e cv--
��r km-A Ig � ,n cr y &t�1a c� -� ��t i �(Ie� �ffl"C J'Q-1
. (AV< �Aa►'aowy ib CAI"s e-�- R L w�" 6 z-d y , Sc e s M R O-�,cr
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3. Describe Proposer's financial capability to perform the Contract. State or describe the firm's financial strength and
rating, bonding capacity, and insurance coverage limits. State whether the firm, or any of the firm's past or present
owners, principal shareholders or stockholders, or officers, have been a debtor party to a bankruptcy, receivership, or
insolvency proceeding in the last 7 years, and identify any such debtor party by name and relationship to or position
with your firm.
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Proposal Forms COMM/SVCS v.05,31.2019
Page 37 of 63
ArB r oa d
Couperative Purchasing
12007 Research Boulevard .Austin,Texas 78759-2439 • PH: 800-695-2919 • FAX: 800-211-5454 • buvboard.com
4. Does your company have any outstanding financial judgments and/or is it currently in default on any loan or financing
agreement? If so, provide detailed information on the nature of such items and prospects for resolution.
i
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5. List all contracts, if any, in the last 10 years on which Proposer has defaulted, failed to complete or deliver the work, or
that have been terminated for any reason. For each such contract, provide the project name, scope, value and date
and the name of the procuring entity. Fully explain the circumstances of the default, failure to complete or deliver the
work, or termination.
6. List all litigation or other legal proceedings (including arbitration proceedings), if any, in the last 10 years brought
against your firm, or any of the firm's past or present owners, principal shareholders or stockholders, officers, agents or
employees, that relates to or arises from a contract similar to this Contract or the work contemplated under this
Contract. Provide the style of the lawsuit or proceeding (name of parties and court or tribunal in which filed), nature of
the claim, and resolution or current status.
By signature below, I certify that the information contained in and/or attached to this Proposal Invitation
Questionnaire in response to the above questions is true and correct and that I am authorized by my
company to mace this certification.
a1�{� �t.l., �.LG•
Company Name
Sign
a re Authorized Company Official
i
Proposal Forms COMMISVCS v.05.31.2019
Page 38 of 63
I
i
Board®
Cooperative Purchasing
12007 Research Boulevard • Austin,Texas 78759-2439 • PH: 800-695-7919 • FAX: 800-211-5454 • buyboard.com
REQUIRED FORMS CHECKLIST
(Please check(r/)the Following)
1
FA Completed: Proposer's Agreement and Signature
Completed: Vendor Contact Information
Completed: Felony Conviction Disclosure and Debarment Certification
Resident Cam Completed: Nonresident Certification
p 1
Completed: No Israel Boycott Certification
Completed: No Excluded Nation or Foreign Terrorist Organization Certification
Completed: Historically Underutilized Business (HUB) Certification)
[� Completed: Construction Related Goods and Services Affirmation
Completed: Deviation/Compliance
[� Completed: Location/Authorized Seller Listings
Completed: Manufacturer Dealer Designation
[� Completed: Texas Regional Service Designation
Completed: State Service Designation
Completed: National Purchasing Cooperative Vendor Award Agreement
L ' Completed: Federal and State/Purchasing Cooperative Experience
DJ Completed: Governmental References
/
Completed: Marketing Strategy
Completed: Confidential/Proprietary Information
Completed: Vendor Business Name with IRS Form W-9
Completed: EDGAR Vendor Certification
Completed: Proposal Invitation Questionnaire
[� Completed: Required Forms Checklist
Completed: Proposal Specification Form with Catalogs/Pricelists
*Catalags/Pricelists must be submitted rvlth proposal response or response will not be considered.
Proposal Forms COMM/SVCS v.05.31.2019
Page 39 of 63
Exhibit C
CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ
For vendor doing business with local governmental entity
This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session. OFFICE USE ONLY
This questionnaire is being filed in accordance with Chapter 176, Local Government Code,by a vendor who Date Received
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 filed with the records administrator of the local governmental entity not later
than the 71h business day after the date the vendor becomes aware of facts that require the statement to be
filed. See Section 176.006(a-1), Local Government Code.
A vendor commits an offense if the vendor knowingly violates Section 176.006, Local Government Code.An
offense under this section is a misdemeanor.
11 Name of vendor who has a business relationship with local governmental entity.
2
Check this box if you are filing an update to a previously filed questionnaire.(The law requires that you file an updated
completed questionnaire with the appropriate filing authority not later than the 7th business day after the date on which
you became aware that the originally filed questionnaire was incomplete or inaccurate.)
3 Name of local government officer about whom the information is being disclosed.
Name of Officer
41 Describe each employment or other business relationship with the local government officer, or a family member of the
officer,as described by Section 176.003(a)(2)(A). Also describe any family relationship with the local government officer.
Complete subparts A and B for each employment or business relationship described. Attach additional pages to this Form
CIO as necessary.
A. Is the local government officer or a family member of the officer receiving or likely to receive taxable income,
other than investment income, from the vendor?
F] Yes F-1 No
B. Is the vendor receiving or likely to receive taxable income,other than investment income,from or at the direction
of the local government officer or a family member of the officer AND the taxable income is not received from the
local governmental entity?
El Yes F-1 No
JJ Describe each employment or business relationship that the vendor named in Section 1 maintains with a corporation or
other business entity with respect to which the local government officer serves as an officer or director, or holds an
ownership interest of one percent or more.
s
ElCheck this box if the vendor has given the focal government officer or a family member of the officer one or more gifts �
as described in Section 176.003(a)(2)(B), excluding gifts described in Section 176.003(a-1).
7
Sign re of vendor doing business with the governmental entity Date
Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 1/1/2021
i
CONFLICT OF INTEREST QUESTIONNAIRE
For vendor doing business with local governmental entity
A complete copy of Chapter 176 of the Local Government Code maybe found at http://www.statutes.Iegis.state.tx.us/
Docs/LG/htm/LG.176.htm. For easy reference, below are some of the sections cited on this form.
Local Government Code§176.001(1-a):"Business relationship"means a connection between two or more parties
based on commercial activity of one of the parties. The term does not include a connection based on:
(A) a transaction that is subject to rate or fee regulation by a federal, state, or local governmental entity or an
agency of a federal, state, or local governmental entity;
(B) a transaction conducted at a price and subject to terms available to the public; or
(C) a purchase or lease of goods or services from a person that is chartered by a state or federal agency and
that is subject to regular examination by, and reporting to, that agency.
Local Government Code§176.003(a)(2)(A)and(B):
(a) A local government officer shall file a conflicts disclosure statement with respect to a vendor if:
(2) the vendor:
(A) has an employment or other business relationship with the local government officer or a
family member of the officer that results in the officer or family member receiving taxable
income, other than investment income, that exceeds $2,500 during the 12-month period
preceding the date that the officer becomes aware that
(i) a contract between the local governmental entity and vendor has been executed;
or
(ii) the local governmental entity is considering entering into a contract with the
vendor;
(B) has given to the local government officer or a family member of the officer one or more gifts
that have an aggregate value of more than$100 in the 12-month period preceding the date the
officer becomes aware that:
(i) a contract between the local governmental entity and vendor has been executed; or
(ii) the local governmental entity is considering entering into a contract with the vendor.
Local Government Code§ 176.006(a)and (a-1)
(a) A vendor shall file a completed conflict of interest questionnaire if the vendor has a business relationship
with a local governmental entity and:
(1) has an employment or other business relationship with a local government officer of that local
governmental entity,or a family member of the officer,described by Section 176.003(a)(2)(A);
(2) has given a local government officer of that local governmental entity, or a family member of the
officer,one or more gifts with the aggregate value specified by Section 176.003(a)(2)(B),excluding any
gift described by Section 176.003(a-1);or
(3) has a family relationship with a local government officer of that local governmental entity.
(a-1) The completed conflict of interest questionnaire must be filed with the appropriate records administrator
not later than the seventh business day after the later of:
(1) the date that the vendor:
(A) begins discussions or negotiations to enter into a contract with the local governmental
entity; or
(B) submits to the local governmental entity an application,response to a request for proposals
or bids, correspondence, or another writing related to a potential contract with the local
governmental entity;or
(2) the date the vendor becomes aware:
(A) of an employment or other business relationship with a local government officer, or a
family member of the officer,described by Subsection(a);
(B) that the vendor has given one or more gifts described by Subsection (a);or
(C) of a family relationship with a local government officer.
Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 1/1/2021