HomeMy WebLinkAboutContract 59757CSC No. 59757
CITY OF FORT WORTH
SOLE SOURCE PURCHASE AGREEMENT
This Sole Source Purchase Agreement ("Agreement") is entered into by and between LBS Enterprises,
LLC dba Allstates coating Company ("Seller") and the City of Fort Worth, ("Buyer"), a Texas home
rule municipal corporation.
The Sole Source Purchase Agreement includes the following documents which shall be construed in the
order of precedence in which they are listed:
1. This Sole Source Purchase Agreement;
2. Exhibit A — Terms and Conditions;
3. Exhibit B —
[Seller's Quote, Scope of Services or Purchase Order];
4. Exhibit C —
Seller's Sole Source Justification Letter;
5. Exhibit D
— Sole Source Procurement Justification; and
6. Exhibit E —
Conflict of Interest Questionnaire.
Exhibits A, B, C, D and E, which are attached hereto and incorporated herein, are made a part of this
Agreement for all purposes.
The undersigned represents and warrants that he or she has the power and authority to execute this
Agreement and bind the respective Seller. Seller and Buyer have caused this Agreement to be executed
by their duly authorized representatives to be effective as of the date signed below.
[Executed effective as of the date signed by the Assistant City Manager below.] / [ACCEPTED AND AGREED:]
City:
City of Fort Worth
By:
Name: William Johnson
Title: Assistant City Manager
Date: J u n 1, 2023
Vendor:
LBS Enterprises, L.L.C. dba Allstates Coating Company
By: Trace, on(May 28. 202312:14 CDT)
Name: Tracy A. Charlson
Title: President
Date:
OFFICIAL RECORD
CITY SECRETARY
FT. WORTH, TX
CITY OF FORT WORTH INTERNAL ROUTING PROCESS:
Approval Recommended:
x
By: Lauren Pneur(May 31, 202312:05 CDT)
Name Lauren Prieur
Title: TPW Director
Approved as to Form and Legality:
1 �17,n 4
By:
Name: Jeremy Anato-Mensah
Title: Assistant City Attorney
Contract Authorization:
M&C:
Contract Compliance Manager:
By signing I acknowledge that I am the person
responsible for the monitoring and administration
of this contract, including ensuring all performance
and reporting requirements.
By:
Name: Lakeesha Dodson
Title: Sr. Administrative Assistant
City Secretary:
By:
Name: Jannette Goodall
Title: City Secretary
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OFFICIAL RECORD
CITY SECRETARY
FT. WORTH, TX
Exhibit A
City of Fort Worth Standard Terms and Conditions
1.0 DEFINITION OF BUYER
The City of Fort Worth, its officers, agents, servants, authorized employees, vendors
and subcontractors who act on behalf of various City departments, bodies or agencies.
2.0 DEFINITION OF SELLER
The Vendor(s), consultant, supplier, its officers, agents, servants, employees, vendors
and subcontractors, or other provider of goods and/or services who act on behalf of the
entity under a contract with the City of Fort Worth.
3.0 TERM
This Agreement shall begin on the date signed by the Buyer's signatory April 27,
2 0 2 4 ("Effective Date") and shall expire on April 28, 2024 ("Expiration Date"),
unless terminated earlier in accordance with this Agreement ("Initial Term"). Buyer
shall have the option, in its sole discretion, to renew this Agreement under the same
terms and conditions, for up to () one-year renewal options, at Buyer's sole
discretion.
4.0 PUBLIC INFORMATION
Buyer is a government entity under the laws of the State of Texas and all documents
held or maintained by Buyer are subject to disclosure under the Texas Public
Information Act. In the event there is a request for information marked Confidential or
Proprietary, Buyer shall promptly notify Seller. It will be the responsibility of Seller
to submit reasons objecting to disclosure. A determination on whether such reasons are
sufficient will not be decided by Buyer, but by the Office of the Attorney General of
the State of Texas or by a court of competent jurisdiction. The Parties agree that
nothing contained within this Agreement is considered proprietary or trade secret
information and this agreement may be released in the event that it is requested.
5.0 PROHIBITION AGAINST PERSONAL INTEREST IN CONTRACTS
No officer or employee of Buyer shall have a financial interest, direct or indirect, in
any contract with Buyer or be financially interested, directly or indirectly, in the sale to
Buyer of any land, materials, supplies or services, except on behalf of Buyer as an
officer or employee. Any willful violation of this section shall constitute malfeasance
in office, and any officer or employee found guilty thereof shall thereby forfeit his
office or position Any violation of this section with the knowledge, expressed or
implied, of the person or corporation contracting with the City Council shall render the
contract invalid by the City Manager or the City Council. (Chapter XXVII, Section
16, City of Fort Worth Charter)
6.0 ORDERS
6.1 No employees of the Buyer or its officers, agents, servants, vendors or subvendors
who act on behalf of various City departments, bodies or agencies are authorized
to place orders for goods and/or services without providing approved contract
numbers, purchase order numbers, or release numbers issued by the Buyer. The
only exceptions are Purchasing Card orders and emergencies pursuant to Texas
Local Government Code Section 252.022(a)(1), (2), or (3). In the case of
emergencies, the Buyer's Purchasing Division will place such orders.
6.2 Acceptance of an order and delivery on the part of the Seller without an approved
contract number, purchase order number, or release number issued by the Buyer
may result in rejection of delivery, return of goods at the Seller's cost and/or non-
payment.
7.0 SELLER TO PACKAGE GOODS
Seller will package goods in accordance with good commercial practice. Each shipping
container shall be clearly and permanently marked as follows: (a) Seller's name and
address: (b) Consignee's name, address and purchase order or purchase change order
number; (c) Container number and total number of containers, e.g., box 1 of 4 boxes; and
(d) Number of the container bearing the packing slip. Seller shall bear the cost of packaging
unless otherwise provided. Goods shall be suitably packed to secure lowest transportation
costs and to conform to requirements of common carriers and any applicable specifications.
Buyer's count or weight shall be final and conclusive on shipments not accompanied by
packing lists.
8.0 SHIPMENT UNDER RESERVATION PROHIBITED
Seller is not authorized to ship the goods under reservation, and no tender of a bill of lading
will operate as a tender of goods.
9.0 TITLE AND RISK OF LOSS
The title and risk of loss of the goods shall not pass to Buyer until Buyer actually receives
and takes possession of the goods at the point or points of delivery after inspection and
acceptance of the goods.
10.0 DELIVERY TERMS AND TRANSPORTATION CHARGES
Freight terms shall be F.O.B. Destination, Freight Prepaid and Allowed.
11.0 PI,ACFOFDELIVERY
The place of delivery shall be set forth in the "Ship to" block of the purchase order,
purchase change order, or release order.
12.0 RIGHT OF INSPECTION
Buyer shall have the right to inspect the goods upon delivery before accepting them. Seller
shall be responsible for all charges for the return to Seller of any goods rejected as being
nonconforming under the specifications.
13.0 INVOICES
13.1 Seller shall submit separate invoices in duplicate, on each purchase order or
purchase change order after each delivery. Invoices shall indicate the purchase
order or purchase change order number. Invoices shall be itemized and
transportation charges, if any, shall be listed separately. A copy of the bill of lading
and the freight waybill, when applicable, should be attached to the invoice. Seller
shall mail or deliver invoices to Buyer's Department and address as set forth in the
block of the purchase order, purchase change order or release order entitled "Ship
to." Payment shall not be made until the above instruments have been submitted
after delivery and acceptance of the goods and/or services.
13.2 Seller shall not include Federal Excise, State or City Sales Tax in its invoices. The
Buyer shall furnish a tax exemption certificate upon Seller's request.
12.3 Payment. All payment terms shall be "Net 30 Days" unless otherwise agreed to in
writing. Before the 1st payment is due to Seller, Seller shall register for direct
deposit payments prior to providing goods and/or services using the forms posted
on the City's website".
14.0 PRICE WARRANTY
14.1 The price to be paid by Buyer shall be that contained in Seller's proposals which
Seller warrants to be no higher than Seller's current prices on orders by others for
products and services of the kind and specification covered by this agreement for
similar quantities under like conditions and methods of purchase. In the event Seller
breaches this warranty, the prices of the items shall be reduced to the prices
contained in Seller's proposals, or in the alternative upon Buyer's option, Buyer
shall have the right to cancel this contract without any liability to Seller for breach
or for Seller's actual expense. Such remedies are in addition to and not in lieu of
any other remedies which Buyer may have in law or equity.
14.2 Seller warrants that no person or selling agency has been employed or
retained to solicit or secure this contract upon an agreement or understanding for
commission, percentage, brokerage or contingent fee, excepting employees of an
established commercial or selling agency that is maintained by Seller for the
purpose of securing business. For breach or violation of this warranty, Buyer
shall have the right, in addition to any other right or rights arising pursuant to
said purchase(s), to cancel this contract without liability and to deduct from the
contract price such commission percentage, brokerage or contingent fee, or
otherwise to recover the full amount thereof.
15.0 PRODUCT WARRANTY
Seller shall not limit or exclude any express or implied warranties and any attempt to do
so shall render this contract voidable at the option of Buyer. Seller warrants that the
goods furnished will conform to Buyer's specifications, drawings and descriptions
listed in the proposal invitation, and the sample(s) furnished by Seller, if any. In the
event of a conflict between Buyer's specifications, drawings, and descriptions, Buyer's
specifications shall govern.
16.0 SAFETY WARRANTY
Seller warrants that the product sold to Buyer shall conform to the standards
promulgated by the U.S. Department of Labor under the Occupational Safety and
Health Act (OSHA) of 1970, as amended. In the event the product does not conform to
OSHA standards, Buyer may return the product for correction or replacement at Seller's
expense. In the event Seller fails to make appropriate correction within a reasonable
time, any correction made by Buyer will be at Seller's expense. Where no correction is
or can be made, Seller shall refund all monies received for such goods within thirty (30)
days after request is made by Buyer in writing and received by Seller. Notice is
considered to have been received upon hand delivery, or otherwise in accordance with
Section 29.0 of these terms and conditions. Failure to make such refund shall constitute
breach and cause this contract to terminate immediately
17.0 SOFTWARE LICENSE TO SELLER
If this purchase is for the license of software products and/or services, and unless
otherwise agreed, Seller hereby grants to Buyer, a perpetual, irrevocable, non-
exclusive, nontransferable, royalty free license to use the software. This software is
"proprietary" to Seller, and is licensed and provided to the Buyer for its sole use for
purposes under this Agreement and any attached work orders or invoices. The Buyer
may not use or share this software without permission of the Seller; however Buyer may
make copies of the software expressly for backup purposes.
18.0 WARRANTY AGAINST INFRINGEMENT OF INTELLECTUAL PROPERTY
18.1 The SELLER warrants that all Deliverables, or any part thereof, furnished
hereunder, including but not limited to: programs, documentation, software,
analyses, applications, methods, ways, and processes (in this Section each
individually referred to as a "Deliverable" and collectively as the "Deliverables,")
do not infringe upon or violate any patent, copyrights, trademarks, service
marks, trade secrets, or any intellectual property rights or other third party
proprietary rights, in the performance of services under this Agreement.
18.2 SELLER shall be liable and responsible for any and all claims made against the
Buyer for infringement of any patent, copyright, trademark, service mark, trade
secret, or other intellectual property rights by the use of or supplying of any
Deliverable(s) in the course of performance or completion of, or in any way
connected with providing the services, or the Buyer's continued use of the
Deliverable(s) hereunder;
18.3 SELLER agrees to defend, settle, or pay, at its own cost and expense, any claim
or action against Buyer for infringement of any patent, copyright, trade mark,
trade secret, or similar property right arising from Buyer's use of the software
and/or documentation in accordance with this Agreement, it being understood
that this agreement to defend, settle or pay shall not apply if Buyer modifies or
misuses the software and/or documentation. So long as SELLER bears the cost
and expense of payment for claims or actions against Buyer pursuant to this
section, SELLER shall have the right to conduct the defense of any such claim
or action and all negotiations for its settlement or compromise and to settle or
compromise any such claim; however, Buyer shall have the right to fully
participate in any and all such settlement, negotiations, or lawsuit as necessary
to protect Buyer's interest, and Buyer agrees to cooperate with SELLER in
doing so. In the event Buyer, for whatever reason, assumes the responsibility
for payment of costs and expenses for any claim or action brought against Buyer
for infringement arising under this Agreement, Buyer shall have the sole right
to conduct the defense of any such claim or action and all negotiations for its
settlement or compromise and to settle or compromise any such claim;
however, SELLER shall fully participate and cooperate with Buyer in defense
of such claim or action. Buyer agrees to give SELLER timely written notice of
any such claim or action, with copies of all papers Buyer may receive relating
thereto. Notwithstanding the foregoing, Buyer's assumption of payment of
costs or expenses shall not eliminate SELLER's duty to indemnify Buyer under
this Agreement. If the software and/or documentation or any part thereof is held
to infringe and the use thereof is enjoined or restrained or, if as a result of a
settlement or compromise, such use is materially adversely restricted, SELLER
shall, at its own expense and as Buyer's sole remedy, either: (a) procure for
Buyer the right to continue to use the software and/or documentation; or (b)
modify the software and/or documentation to make it non -infringing, provided
that such modification does not materially adversely affect Buyer's authorized
use of the software and/or documentation; or (c) replace the software and/or
documentation with equally suitable, compatible, and functionally equivalent
non -infringing software and/or documentation at no additional charge to Buyer;
or (d) if none of the foregoing alternatives is reasonably available to SELLER
terminate this Agreement, and refund all amounts paid to SELLER by Buyer,
subsequent to which termination Buyer may seek any and all remedies available
to Buyer under law; and
18.4 The representations, warranties, and covenants of the parties contained in section
13 through 17 of this Agreement will survive the termination and/or expiration of
this Agreement.
19.0 OWNERSHIP OF WORK PRODUCT
Seller agrees that any and all analyses, evaluations, reports, memoranda, letters, ideas,
processes, methods, programs, and manuals that were developed, prepared, conceived,
made or suggested by the Seller for the Buyer pursuant to a Work Order, including all
such developments as are originated or conceived during the term of the Contract and
that are completed or reduced to writing thereafter (the "Work Product") and Seller
acknowledges that such Work Product may be considered "work(s) made for hire" and
will be and remain the exclusive property of the Buyer. To the extent that the Work
Product, under applicable law, may not be considered work(s) made for hire, Seller
hereby agrees that this Agreement effectively transfers, grants, conveys, and assigns
exclusively to Buyer, all rights, title and ownership interests, including copyright,
which Seller may have in any Work Product or any tangible media embodying such
Work Product, without the necessity of any further consideration, and Buyer shall be
entitled to obtain and hold in its own name, all Intellectual Property rights in and to the
Work Product. Seller for itself and on behalf of its vendors hereby waives any property
interest in such Work Product.
20.0 CANCELLATION
Buyer shall have the right to cancel this contract immediately for default on all or any
part of the undelivered portion of this order if Seller breaches any of the terms hereof,
including warranties of Seller. Such right of cancellation is in addition to and not in lieu
of any other remedies, which Buyer may have in law or equity.
21.0 TERMINATION
21.1 Written Notice. The purchase of goods under this order may be terminated in
whole or in part by Buyer, with or without cause, at any time upon the delivery
to Seller of a written "Notice of Termination" specifying the extent to which the
goods to be purchased under the order is terminated and the date upon which
such termination becomes effective. Such right of termination is in addition to
and not in lieu of any other termination rights of Buyer as set forth herein.
21.2 Non-annronriation of Funds. In the event no funds or insufficient funds are
appropriated by Buyer in any fiscal period for any payments due hereunder,
Buyer will notify Seller of such occurrence and this Agreement shall terminate
on the last day of the fiscal period for which appropriations were received
without penalty or expense to Buyer of any kind whatsoever, except as to the
portions of the payments herein agreed upon for which funds have been
appropriated.
21.3 Duties and Oblieations of the Parties. Upon termination of this Agreement for
any reason, Seller shall only be compensated for items requested by the Buyer
and delivered prior to the effective date of termination, and Buyer shall not be
liable for any other costs, including any claims for lost profits or incidental
damages. Seller shall provide Buyer with copies of all completed or partially
completed documents prepared under this Agreement. In the event Seller has
received access to Buyer Information or data as a requirement to perform
services hereunder, Seller shall return all Buyer provided data to Buyer in a
machine-readable format or other format deemed acceptable to Buyer.
22.0 ASSIGNMENT/ DELEGATION
No interest, obligation or right of Seller, including the right to receive payment, under
this contract shall be assigned or delegated to another entity without the express written
consent of Buyer. Any attempted assignment or delegation of Seller shall be wholly void
and totally ineffective for all purposes unless made in conformity with this paragraph.
Prior to Buyer giving its consent, Seller agrees that Seller shall provide, at no additional
cost to Buyer, all documents, as determined by Buyer, that are reasonable and
necessary to verify Seller's legal status and transfer of rights, interests, or obligations to
another entity. The documents that may be requested include, but are not limited to,
Articles of Incorporation and related amendments, Certificate of Merger, IRS Form W-
9 to verify tax identification number, etc. Buyer reserves the right to withhold all
payments to any entity other than Seller, if Seller is not in compliance with this
provision. If Seller fails to provide necessary information in accordance with this
section, Buyer shall not be liable for any penalties, fees or interest resulting therefrom.
23.0 WAIVER
No claim or right arising out of a breach of this contract can be discharged in whole or
in part by a waiver or renunciation of the claim or right unless the waiver or
renunciation is supported by consideration in writing and is signed by the aggrieved
party.
24.0 MODIFICATIONS
This contract can be modified or rescinded only by a written agreement signed by both
parties.
25.0 THE AGREEMENT
In the absence of an otherwise negotiated contract, or unless stated otherwise, the
Agreement between Buyer and Seller shall consist of these Standard Terms and
Conditions together with any attachments and exhibits. This Agreement is intended by
the parties as a final expression of their agreement and is intended also as a complete
and exclusive statement of the terms of their agreement. No course of prior dealings
between the parties and no usage of trade shall be relevant to supplement or explain
any term used in this Agreement. Acceptance of or acquiescence in a course of
performance under this Agreement shall not be relevant to determine the meaning of
this Agreement even though the accepting or acquiescing parry has knowledge of the
performance and opportunity for objection. Whenever a term defined by the Uniform
Commercial Code (UCC) is used in this Agreement, the definition contained in the
UCC shall control. In the event of a conflict between the contract documents, the order
of precedence shall be these Standard Terms and Conditions, and the Seller's Quote.
26.0 APPLICABLE LAW/ VENUE
This agreement shall be governed by the Uniform Commercial Code wherever the
term "Uniform Commercial Code" or "UCC" is used. It shall be construed as meaning
the Uniform Commercial Code as adopted and amended in the State of Texas. Both
parties agree that venue for any litigation arising from this contract shall be in Fort
Worth, Tarrant County, Texas. This contract shall be governed, construed and enforced
under the laws of the State of Texas.
27.0 INDEPENDENT CONTRACTORS}
Seller shall operate hereunder as an independent contractor and not as an officer, agent,
servant or employee of Buyer. Seller shall have exclusive control of, and the exclusive
right to control, the details of its operations hereunder, and all persons performing
same, and shall be solely responsible for the acts and omissions of its officers, agents,
employees, vendors and subcontractors. The doctrine of respondent superior shall not
apply as between Buyer and Seller, its officers, agents, employees, vendors and
subcontractors. Nothing herein shall be construed as creating a partnership or joint
enterprise between Buyer and Seller, its officers, agents, employees, vendors and
subcontractors.
28.0 LIABILITY AND INDEMNIFICATION.
28.1 LIABILITY - SELLER SHALL BE LIABLE AND RESPONSIBLE FOR ANY
AND ALL PROPERTY LOSS, PROPERTY DAMAGE AND/OR PERSONAL
INJURY, INCLUDING DEATH, TO ANY AND ALL PERSONS, OF ANY
KIND OR CHARACTER, WHETHER REAL OR ASSERTED, TO THE
EXTENT CAUSED BY THE NEGLIGENT ACT(S) OR OMISSION(S),
MALFEASANCE OR INTENTIONAL MISCONDUCT OF SELLER, ITS
OFFICERS, AGENTS, SERVANTS OR EMPLOYEES.
28.2 GENERAL INDEMNIFICATION - SELLER HEREBY COVENANTS AND
AGREES TO INDEMNIFY, HOLD HARMLESS AND DEFEND BUYER, ITS
OFFICERS, AGENTS, SERVANTS AND EMPLOYEES, FROM AND
AGAINST ANY AND ALL CLAIMS OR LAWSUITS OF ANY KIND OR
CHARACTER, WHETHER REAL OR ASSERTED, FOR EITHER
PROPERTY DAMAGE OR LOSS (INCLUDING ALLEGED DAMAGE OR
LOSS TO SELLER'S BUSINESS AND ANY RESULTING LOST PROFITS)
AND/OR PERSONAL INJURY, INCLUDING DEATH, TO ANY AND
ALLPERSONS, ARISING OUT OF OR IN CONNECTION WITH THIS
AGREEMENT, TO THE EXTENT CAUSED BY THE NEGLIGENT ACTS OR
OMISSIONS OR MALFEASANCE OF SELLER, ITS OFFICERS, AGENTS,
SERVANTS OR EMPLOYEES.
28.3 INTELLECTUAL PROPERTYINDEMNIFICATION -
(a) Seller agrees to defend, settle, or pay, at its own cost and expense, any claim or
action against Buyer for infringement of any patent, copyright, trade mark, trade
secret, or similar property right arising from Buyer's use of the software and/or
documentation in accordance with this Agreement, it being understood that this
agreement to defend, settle or pay shall not apply if Buyer modifies or misuses the
software and/or documentation. So long as Seller bears the cost and expense of
payment for claims or actions against Buyer pursuant to this section, Seller shall
have the right to conduct the defense of any such claim or action and all
negotiations for its settlement or compromise and to settle or compromise any
such claim; however, Buyer shall have the right to fully participate in any and all
such settlement, negotiations, or lawsuit as necessary to protect Buyer's interest,
and Buyer agrees to cooperate with Seller in doing so. In the event Buyer, for
whatever reason, assumes the responsibility for payment of costs and expenses for
any claim or action brought against Buyer for infringement arising under this
Agreement, Buyer shall have the sole right to conduct the defense of any such
claim or action and all negotiations for its settlement or compromise and to settle
or compromise any such claim; however, Seller shall fully participate and
cooperate with Buyer in defense of such claim or action. Buyer agrees to give
Seller timely written notice of any such claim or action, with copies of all papers
Buyer may receive relating thereto. Notwithstanding the foregoing, Buyer's
assumption of payment of costs or expenses shall not eliminate Seller's duty to
indemnify Buyer under this Agreement. If the software and/or documentation or
any part thereof is held to infringe and the use thereof is enjoined or restrained or,
if as a result of a settlement or compromise, such use is materially adversely
restricted, Seller shall, at its own expense and as Buyer's sole remedy, either: (a)
procure for Buyer the right to continue to use the software and/or
documentation; or
(b) modify the software and/or documentation to make it non -infringing,
provided that such modification does not materially adversely affect Buyer's
authorized use of the software and/or documentation; or (c) replace the
software and/or documentation with equally suitable, compatible, and
functionally equivalent non -infringing software and/or documentation at no
additional charge to Buyer; or (d) if none of the foregoing alternatives is
reasonably available to Seller terminate this Agreement, and refund all amounts
paid to Seller by Buyer, subsequent to which termination Buyer may seek any
and all remedies available to Buyer under law.
29.0 SEVERABILITY
In case any one or more of the provisions contained in this agreement shall for any reason,
be held to be invalid, illegal or unenforceable in any respect, such invalidity, illegality or
unenforceability shall not affect any other provision of this agreement, which agreement
shall be construed as if such invalid, illegal or unenforceable provision had never been
contained herein.
30 FISCAL FUNDING LIMITATION
In the event no funds or insufficient funds are appropriated and budgeted in any fiscal
period for payments due under this contract, then Buyer will immediately notify Seller
of such occurrence and this contract shall be terminated on the last day of the fiscal
period for which funds have been appropriated without penalty or expense to Buyer of
any kind whatsoever, except to the portions of annual payments herein agreed upon for
which funds shall have been appropriated and budgeted or are otherwise available.
31 NOTICES TO PARTIES
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 BUYER
City of Fort Worth
Attn: Purchasing Manager
200 Texas Street
Fort Worth, TX 76102-6314
Facsimile: (817) 392-8654
With copy to Fort Worth City Attorney's Office
at the same address
32 NON-DISCRIMINATION
TO SELLER
Allstates Coating Company
Tracey A. Charlson,
100 N. Lee Dr.
Gladewater; Tx 75647
Email: acc@allstatescoating.com
Facsimile:
Seller, for itself, its personal representatives, assigns, subvendors and successors in
interest, as part of the consideration herein, agrees that in the performance of Seller's duties
and obligations hereunder, it shall not discriminate in the treatment or employment of any
individual or group of individuals on any basis prohibited by law. IF ANY CLAIM
ARISES FROM AN ALLEGED VIOLATION OF THIS NON-DISCRIMINATION
COVENANT BY SELLER, ITS PERSONAL REPRESENTATIVES, ASSIGNS,
SUBVENDORS OR SUCCESSORS IN INTEREST, SELLER AGREES TO
ASSUME SUCH LIABILITY AND TO INDEMNIFY AND DEFEND BUYER AND
HOLD BUYER HARMLESS FROM SUCH CLAIM.
33 IMMIGRATION NATIONALITY ACT
Seller shall verify the identity and employment eligibility of its employees who perform
work under this Agreement, including completing the Employment Eligibility Verification
Form (1-9). Upon request by Buyer, Seller shall provide Buyer with copies of all 1-9 forms
and supporting eligibility documentation for each employee who performs work under this
Agreement. Seller shall adhere to all Federal and State laws as well as establish appropriate
procedures and controls so that no services will be performed by any Seller employee
who is not legally eligible to perform such services. SELLER SHALL INDEMNIFY
BUYER AND HOLD BUYER HARMLESS FROM ANY PENALTIES,
LIABILITIES, OR LOSSES DUE TO VIOLATIONS OF THIS PARAGRAPH BY
SELLER, SELLER'S EMPLOYEES, SUBCONTRACTORS, AGENTS, OR
LICENSEES.
Buyer, upon written notice to Seller, shall have the right to immediately terminate this
Agreement for violations of this provision by Seller.
34 HEALTH. SAFETY. AND ENVIRONMENTAL REOUIREMENTS
Services, products, materials, and supplies provided by the Seller must meet or exceed
all applicable health, safety, and the environmental laws, requirements, and standards.
In addition, Seller agrees to obtain and pay, at its own expense, for all licenses, permits,
certificates, and inspections necessary to provide the products or to perform the
services hereunder. Seller shall indemnify Buyer from any penalties or liabilities due
to violations of this provision. Buyer shall have the right to immediately terminate this
Agreement for violations of this provision by Seller.
35 RIGHT TO AUDIT
Seller agrees that Buyer shall, until the expiration of three (3) years after final payment
under this contract, 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 Seller involving transactions relating to this Agreement at no
additional cost to Buyer. Seller agrees that Buyer shall have access during normal
working hours to all necessary Seller facilities and shall be provided adequate and
appropriate work space in order to conduct audits in compliance with the provisions
of this section. Buyer shall give Seller reasonable advance notice of intended audits.
The Buyer's right to audit, as described herein, shall survive the termination and/or
expiration of this Agreement.
36 DISABILITY
In accordance with the provisions of the Americans With Disabilities Act of 1990
(ADA), Seller warrants that it and any and all of its subcontractors will not unlawfully
discriminate on the basis of disability in the provision of services to general public,
nor in the availability, terms and/or conditions of employment for applicants for
employment with, or employees of Seller or any of its subcontractors. Seller warrants
it will fully comply with ADA's provisions and any other applicable federal, state and
local laws concerning disability and will defend, indemnify and hold Buyer harmless
against any claims or allegations asserted by third parties or subcontractors against Buyer
arising out of Seller's and/or its subcontractor's alleged failure to comply with the above -
referenced laws concerning disability discrimination in the performance of this agreement.
37 DISPUTE RESOLUTION
If either Buyer or Seller has a claim, dispute, or other matter in question for breach of duty,
obligations, services rendered or any warranty that arises under this Agreement, the parties
shall first attempt to resolve the matter through this dispute resolution process. The
disputing party shall notify the other party in writing as soon as practicable after
discovering the claim, dispute, or breach. The notice shall state the nature of the dispute
and list the party's specific reasons for such dispute. Within ten (10) business days of
receipt of the notice, both parties shall make a good faith effort, either through email, mail,
phone conference, in person meetings, or other reasonable means to resolve any claim,
dispute, breach or other matter in question that may arise out of, or in connection with this
Agreement. If the parties fail to resolve the dispute within sixty (60) days of the date of
receipt of the notice of the dispute, then the parties may submit the matter to non -binding
mediation upon written consent of authorized representatives of both parties in accordance
with the Industry Arbitration Rules of the American Arbitration Association or other
applicable rules governing mediation then in effect. If the parties submit the dispute to non-
binding mediation and cannot resolve the dispute through mediation, then either party shall
have the right to exercise any and all remedies available under law regarding the dispute.
38 PROHIBITION ON CONTRACTING WITH COMPANIES THAT BOYCOTT
ISRAEL
If Seller has fewer than 10 employees or this Agreement is for less than $100,000, this
section does not apply. Seller acknowledges that in accordance with Chapter 2270 of the
Texas Government Code, the Buyer is prohibited from entering into a contract with a
company 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. The terms "boycott Israel" and "company" shall have the meanings
ascribed to those terms in Section 808.001 of the Texas Government Code. By signing
this contract, Seller certifies that Seller's signature provides written verification
to the Buyer that Seller: (1) does not boycott Israel; and (2) will not boycott Israel
during the term of the contract.
39 Prohibition on Bovcotting Enerfyv Comnanies. Vendor acknowledges that in accordance
with Chapter 2274 of the Texas Government Code, as added by Acts 2021, 87th Leg., R.S.,
S.B. 13, § 2, the City is prohibited from entering into a contract for goods or services that has
a value of $100,000 or more that is to be paid wholly or partly from public funds of the City
with a company with 10 or more full-time employees unless the contract contains a written
verification from the company that it: (1) does not boycott energy companies; and (2) will not
boycott energy companies during the term of the contract. The terms "boycott energy
company" and "company" have the meaning ascribed to those terms by Chapter 2274 of the
Texas Government Code, as added by Acts 2021, 87th Leg., R.S., S.B. 13, § 2. To the extent
that Chapter 2274 of the Government Code is applicable to this Agreement, by signing this
Agreement, Vendor certifies that Vendor's signature provides written verification to the City
that Vendor: (1) does not boycott energy companies; and (2) will not boycott energy
companies during the term of this Agreement.
40 Prohibition on Discrimination Against Firearm and Ammunition Industries. Vendor
acknowledges that except as otherwise provided by Chapter 2274 of the Texas Government
Code, as added by Acts 2021, 87thLeg., R.S., S.B. 19, § 1, the City is prohibited from entering
into a contract for goods or services that has a value of $100,000 or more that is to be paid
wholly or partly from public funds of the City with a company with 10 or more full-time
employees unless the contract contains a written verification from the company that it: (1)
does not have a practice, policy, guidance, or directive that discriminates against a firearm
entity or firearm trade association; and (2) will not discriminate during the term of the contract
against a firearm entity or firearm trade association. The terms "discriminate," "firearm entity"
and "firearm trade association" have the meaning ascribed to those terms by Chapter 2274 of
the Texas Government Code, as added by Acts 2021, 87th Leg., R.S., S.B. 19, § 1. To the
extent that Chapter 2274 of the Government Code is applicable to this Agreement, by signing
this Agreement, Vendor certifies that Vendor's signature provides written verification to the
City that Vendor: (1) does not have a practice, policy, guidance, or directive that discriminates
against a firearm entity or firearm trade association; and (2) will not discriminate against a
firearm entity or firearm trade association during the term of this Agreement.
41 INSURANCE REQUIREMENTS
4 1. 1 Coverage and Limits
(a) Commercial General Liability:
$1,000,000 - Each Occurrence
$2,000,000 - Aggregate
(b) Automobile Liability:
$1,000,000 - Each occurrence on a combined single limit basis
Coverage shall be on any vehicle used by Seller, its employees, agents,
representatives in the course of providing services under this Agreement.
"Any vehicle" shall be any vehicle owned, hired and non -owned.
(c) Worker's Compensation:
Statutory limits according to the Texas Workers' Compensation Act or any
other state workers' compensation laws where the work is being performed
Employers' liability
$100,000 - Bodily Injury by accident; each
accident/occurrence
$100,000 - Bodily Injury by disease; each employee
$500,000 - Bodily Injury by disease; policy limit
(d) Professional Liability (Errors & Omissions):
$1,000,000 - Each Claim Limit
$1,000,000 - Aggregate Limit
Professional Liability coverage may be provided through an
endorsement to the Commercial General Liability (CGL) policy, or a
separate policy specific to Professional E&O. Either is acceptable if
coverage meets all other requirements. Coverage shall be claims -made,
and maintained for the duration of the contractual agreement and for two
(2) years following completion of services provided. An annual
certificate of insurance shall be submitted to Buyer to evidence
coverage.
41.2 General Requirements
41.2.1 The commercial general liability and
automobile liability policies shall name Buyer as an
additional insured thereon, as its interests may appear.
The term Buyer shall include its employees, officers,
officials, agents, and volunteers in respect to the
contracted services.
41.2.2 The workers' compensation policy shall include a Waiver of
Subrogation (Right of Recovery) in favor of Buyer.
41.2.3 A minimum of Thirty (30) days' notice of cancellation or
reduction in limits of coverage shall be provided to Buyer. Ten (10) days'
notice shall be acceptable in the event of non-payment of premium.
Notice shall be sent to the Risk Manager, Buyer of Fort Worth, 200
Texas Street, Fort Worth, Texas 76102, with copies to the Fort Worth
City Attorney at the same address.
41.2.4 The insurers for all policies must be licensed and/or approved to
do business in the State of Texas. All insurers must have a minimum
rating of A- VII in the current A.M. Best Key Rating Guide, or have
reasonably equivalent financial strength and solvency to the satisfaction
of Risk Management. If the rating is below that required, written
approval of Risk Management is required.
41.2.5 Any failure on the part of Buyer to request required insurance
documentation shall not constitute a waiver of the insurance
requirement.
41.2.6 Certificates of Insurance evidencing that Vendor has obtained all
required insurance shall be delivered to the Buyer prior to Vendor
proceeding with any work pursuant to this Agreement.
Exhibit B - Seller's Quote
From:
tac allstatescoatinas.com
To:
Hukill. Tvler
Cc:
is allstatescoatinas.com: is allstatescoatinas.com: ml allstatescoatinas.com
Subject:
QUOTE - Allstates Coatings Cracksealants
Date:
Monday, February 6, 2023 8:58:22 AM
Attachments:
imaoe001.ono
CAUTION: This email originated from outside of the City of Fort Worth email system. Do not click any links or open
attachments unless you recognize the sender and know the content is safe.
We are pleased to quote you the following shipment of cracksealants:
2 X Crac Shot Drum Pumps - $4,000.00 each: $ 8,000.00
2 X 55-Gallon Drums FLEX CRETE Concrete Joint and Cracksealant - $1,345.00 each: $ 2,690.00
40 X 55-Gallon Drums SUPER FLEX Cracksealant - $583.00 each:
$23,320.00
Shipping Charges
1.100.00
TOTAL $35,110.00
This quotation is valid for 90 days. Thank you for your business.
Regards,
Mr. Tracey A. Charlson, CPA
President
Allstates Coatings Company
100 N. Lee Dr.
Gladewater, TX 75647
www.allstatescoatin2s.com
903-845-6436 x205 Office
903-445-8684 Cell
FC
Exhibit C — Sole Source Justification Letter
Allstates Coatings Company'
100 N. LEE DR. • GLADEWATER, TEXAS 75647
903-845-6436 • FAX:903-845-5626
MANUFACTURERS OF PAVING MAINTENANCE PRODUCTS, SPECIALTY COATINGS AND PAINTS
February 21, 2018
To Whom It May Concern:
This letter is to confirm that the ALT-654 Super Flex® is a sole source product. It is the only cold -
applied, asphalt -based, one -part fuel resistant sealant that also meets the performance
characteristics of ASTM D3405 and D6690. it is manufactured, sold and distributed exclusively
by Allstates Coatings Company. Other than Allstates distribution network, no other company,
makes or sells a similar or competing product.
Exhibit C — Sole Source Justification Letter
fq!o Allstates Coatings Company®
100 N. LEE DR. • GLADEWATER, TEXAS 75647
903-845-6436 • FAX:903-845-5626
MANUFACTURERS OF PAVING MAINTENANCE PRODUCTS, SPECIALTY COATINGS AND PAINTS
March 20, 2020
To Whom It May Concern:
This letter is to confirm that the Crac ShotTm Drum Pump System offered by Allstates
Coatings Company, is designed to work with our cold pour crack sealants by maximizing
product flow and reducing resistance due to viscosity. The Crac ShotTm Drum Pump is a
double diaphragm -Teflon lined pump capable of moving 100+ K.U. adhesive liquids
through a '/2" discharge system and redirectional emulsion enhancement with no clogging,
adverse flow factors or emulsion shearing. It is manufactured, sold and distributed
exclusively by Allstates Coatings Company. Other than Allstates distribution network, no
other company, makes or sells a similar or competing product.
Exhibit C — Sole Source Justification Letter
f�
February 21, 2018
Allstates Coatings Company°
100 N. LEE DR. • GLADEWATER, TEXAS 75647
903-845-6436 • FAX:903-845-5626
MANUFACTURERS OF PAVING MAINTENANCE PRODUCTS, SPECIALTY COATINGS AND PAINTS
To Whom It May Concern:
This letter is to confirm that the ALT-671 Flex Crete" is a sole source product. It is the only
waterbased gray single -component, ready -to -use, ultra -low modulus, pourable, neutral cure
elastomeric emulsion that meets ASTM Standards for Elastomeric Joint Sealants. It is
manufactured, sold and distributed exclusively by Allstates Coatings Company. Other than
Allstates distribution network, no other company, makes or sells a similar or competing product.
Exhibit C — Sole Source Justification Letter
aw
June 1, 2022
CCCCC COMOMQO'l C00imparay,
100 N. LEE DR. • GLADEWATER, TEXAS 75647
903-845-6436 • FAX:903-845-5626
MANUFACTURERS OF PAVING MAINTENANCE PRODUCTS, SPECIALTY COATINGS AND PAINTS
To Whom It May Concern:
This letter is to confirm that the ALT-674 SealFleXTm 6690 is a SOLE SOURCE product. SealFleX`M
6690 is the ONLY product that meets both ASTM D6690 (Standard Specification for Joint and
Crack Sealants, Hot Applied, for Concrete and Asphalt Pavements) and ASTM C920 (Standard
Specification for Elastomeric Joint Sealants).
It is manufactured, sold and distributed exclusively by Allstates Coatings Company. Other than
Allstates distribution network, no other company, makes or sells a similar or competing product.
Exhibit D — Sole Source Procurement Justification
FORT WORTH
CITY OF FORT WORTH
CHAPTER 252 EXEMPTION FORM
Instructions: Fill out the entire form with detailed information. Once you have completed this form,
provide it to the Purchasing attorney for review. The attorney will review the information you have
provided to determine whether an exemption to Chapter 252's biding requirements is defensible.
If you are printing this form to provide to Legal, please do not provide the Primer portion. Failure
to provide sufficient information may result in follow up questions and cause a delay in the
attorney's determination.
Requesting Department:
Name of Contract Manager:
Department's Attorney:
Item or Service sought:
Goods:
Service:
Anticipated Amount:
Vendor:
Section 1: General Information
TPW
Lakeesha Dodson
Doug Black
M
n
$300,000
Current/Prior Agreement for item/service:
CSC or Purchase Order #:
Amount:
Projected M&C Date:
How will this item or service be used?
street maintenance.
Allstates Coatincs
Yes ❑
[N/A]
[N/A]
[N/A]
Material for our crack seal program, which is part of
Has your department started a requisition or otherwise contacted the Purchasing Division related
to obtaining this good/service? Yes ❑ No
If yes, please provide requisition number or brief explanation of contact with
Purchasing Division: [N/A]
Page 1 of 4
Exhibit D — Sole Source Procurement Justification
Section 2: Claimed Exemption and Justification (Other than sole source)
NOTE - For a claimed sole -source exemption, complete Section 3.
Please indicate the non -sole -source exemption you believe applies to the purchase and provide
information to support its applicability. Please refer to the Exemption Primer for detailed
information about common exemptions:
[] A procurement necessary to preserve or protect the public health or safety of the City
of Fort Worth's residents;
Fj A procurement necessary because of unforeseen damage to public machinery,
equipment, or other property;
R A procurement for personal, professional, or planning services;
R A procurement for work that is performed and paid for by the day as the work
progresses;
[] A purchase of land or a right-of-way;
[] Paving drainage, street widening, and other public improvements, or related matters, if
at least one-third of the cost is to be paid by or through special assessments levied on
property that will benefit from the improvements;
[] A public improvement project, already in progress, authorized by the voters of the
municipality, for which there is a deficiency of funds for completing the project in
accordance with the plans and purposes authorized by the voters;
[] A payment under a contract by which a developer participates in the construction of a
public improvement as provided by Subchapter C, Chapter 212;
[] Personal property sold:
• at an auction by a state licensed auctioneer;
• at a going out of business sale held in compliance with Subchapter F,
Chapter 17, Business & Commerce Code;
• by a political subdivision of this state, a state agency of this state, or an
entity of the federal government; or
• under an interlocal contract for cooperative purchasing administered by a
regional planning commission established under Chapter 391;
[] Services performed by blind or severely disabled persons;
[] Goods purchased by a municipality for subsequent retail sale by the municipality;
[] Electricity; or
Page 2 of 4
Exhibit D — Sole Source Procurement Justification
R Advertising, other than legal notices.
Please provide details and facts to explain why you believe the exemption applies to the
purchase. You may also attach documentation to this form. [INSERT DETAILED
EXPLANATION AS TO HOW/WHY CLAIMED EXCEPTION APPLIES TO THIS
PURCHASE]
Section 3: Claimed Sole -Source Exemption and Justification
NOTE - For any non -sole -source exemption, complete Section 2.
Please indicate the sole -source exemption you believe applies to the purchase and provide
information to support its applicability. Please refer to the Exemption Primer for detailed
information about common exemptions
*A procurement of items that are available from only one source, including:
• items that are available from only one source because of patents, copyrights,
secret processes, or natural monopolies;
• films, manuscripts, or books;
• gas, water, and other utility services;
• captive replacement parts or components for equipment;
• books, papers, and other library materials for a public library that are
available only from the persons holding exclusive distribution rights to the
materials; and
• management services provided by a nonprofit organization to a municipal
museum, park, zoo, or other facility to which the organization has provided
significant financial or other benefits;
How did you determine that the item or service is only available from one source?
The companv produces their own products and thev have provided sole source letters to prove it.
Attach screenshots and provide an explanation of any independent research you conducted,
through internet searches, searching cooperatives, or discussions with others knowledgeable on
the subject matter that corroborate that the item is available only from a single source.
I did not conduct my own independent research. Attached are the sole source justification
letters.
Did you attach a sole source justification letter? X Yes ❑ No
Page 3 of 4
Exhibit D — Sole Source Procurement Justification
Describe the uniqueness of the item or service (e.g. compatibility or patent issues, etc.). This is a
crack seal product that can be applied vear round as opposed to the current product that we use.
This material is also a cold applied product, which means we do not need expensive equipment
to apply it. They have created their own material pump.
Section 4: Attornev Determination
With the facts provided by the department, is the use of the claimed exemption defensible if the
City were to be challenged on this purchase? M Yes ❑ No.
Was there anything attached to this form that was relied on in making this determination?
M Yes ❑ No.
If yes, please explain:The department provided sole source letters.
Was there anything not included on this form or attached hereto that was relied on in making this
determination? [] Yes M No.
If yes, please explain: [EXPLAIN OUTSIDE SOURCE OF INFORMATION]
Will the standard terms and conditions apply? M Yes ❑ No.
Will the contract require special terms?
Will the contract require review by the department attorney?
Approved By:
V44
e;Sian
nato-Mensah
City Attorney
[] Yes No.
Yes [] No.
Date: 12/6/2022
Page 4 of 4
Exhibit E - CONFLICT OF INTEREST
QUESTIONNAIRE
Pursuant to Chapter 176 of the Local Government Code, any person or agent of a
person who contracts or seeks to contract for the sale or purchase of property, goods,
or services with a local governmental entity (i.e. The City of Fort Worth) must disclose
in the Questionnaire Form CIQ ("Questionnaire") the person's affiliation or business
relationship that might cause a conflict of interest with the local governmental entity.
By law, the Questionnaire must be filed with the Fort Worth City Secretary no later
than seven days after the date the person begins contract discussions or negotiations
with the Buyer, or submits an application or response to a request for proposals or bids,
correspondence, or another writing related to a potential agreement with the Buyer.
Updated Questionnaires must be filed in conformance with Chapter 176.
A copy of the Questionnaire Form CIQ is enclosed with the submittal documents. The
form is also available at httn://www.ethics.state.tx.us/forms/CIO.ndf.
If you have any questions about compliance, please consult your own legal counsel.
Compliance is the individual responsibility of each person or agent of a person who is
subject to the filing requirement. An offense under Chapter 176 is a Class C
misdemeanor.
NOTE: If you are not aware of a Conflict of Interest in any business relationship
that you might have with the Buyer, state Seller name in the# 1, use N/A in each
of the areas on the form. However, a signature is required in the #4 box in all
cases.
Exhibit E - CONFLICT OF INTEREST QUESTIONNAIRE
CONFLICT OF INTEREST QUESTIONNAIRE
For vendor doing business with local governmental entity
This questionnaire reflects changes made to the taw by H.B. 23, 04th Leg., Regular Session.
This questionnaire is being filed in accordance with Chapter 176, Local Government Code,
by a vendorwho has a business relationship as defined by Section 176.001(1-a)with a focal
governmental entity and the vendor meets requirements under Section 176.006(a).
By law this questionnaire must be filedwith the records administrator of the local governmental
entity not later than the 7th 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.
J Name of vendor who has a business relationship with local governmental entity.
115-td-e-s 6'0di0q.s Covpraivv
?J I I Check this box if you are flllrrA an update to t?prevlodsly filed questionnaire.
FORM CIQ
OFFICE USE ONLY
SAID Rcc&od
(The law requires that you file an updated completed questionnaire with the appropriate tiling 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 In this section Is being disclosed.
A1J,4
Name of Officer
This section (item 3 including subparts A, B, C, & D) must be completed for each officer with whom the vendor has an
employment or other business relationship 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 likely to receive taxable income, other than investment
income, from the vendor?
r'U(l Yes F�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 named in this section AND the taxable income is not received from the local governmental entity?
1►"A E-] Yes E-1 No
C. Is the filer of this questionnaire employed by 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?
/1/1/' F--] Yes F1 No
D. Dese`ibe each employment or business and family relationship with the local government officer named in this section.
71
Signaturef ofvbor doing business with the governmental entity Date
Adopted 817/2016
18
Seller's Name: 4&ld e� 6alj tj6j s* (/)XPCVI V
v / Seller's Local Address: % d li �� L ea r. 161,1 e 41--,`1
�e f-, -rX
Phone: 903 - ,NS- 6 q3 6 Fax:
Email: 16c& ollVOf23 GOG�7%✓�G],S, d
Name of persons to contact when placing an order or invoice questions:
Name/Title— rdcey i. Clioi>^ seki - FveS; deA
Phone: 90-3 - WS-- &W Fax:
Email:_�da�I �L'r�� G0(,�'Ti vt�S"rs1 G(92 e-0
Name/Title Y'�C SCE,` Gl I-2 v" - j9! !&ClO tq C/ reC417 C a f
Phone: 97R - 9 3a -9j 63 S Fax:
Email: is 9 ezlNaf eS G0d—I-VIES, G 0"
v
Name/Title ,ff M e /! v2 � Qi1G�►''u ►� - � e�j IS"�, G .S �o ✓ ► �r t� � 7` 0 v
Phone: %,,03- yqs- W 6 X vl o3 Fax:
Email: M GL //514 --le S C oa, ; ✓►GI S, (. Oto
Signature Printed Name Date
19