HomeMy WebLinkAboutContract 61227CSC No. 61227
FORT WORTH
CITY OF FORT WORTH
COOPERATIVE PURCHASE AGREEMENT
This Cooperative Purchase Agreement ("Agreement") is entered into by and between A.W.
Chesterton Company ("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;
3. Exhibit B — Cooperative Agency Contract BuyBoard 672-22; 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. If any provisions of the attached Exhibits conflict with the terms herein, are prohibited
by applicable law, conflict with any applicable rule, regulation or ordinance of City, the terms in this
Cooperative Purchase Agreement shall control.
City shall pay Vendor in accordance with the fee schedule in Exhibit A and in accordance with
the provisions of this Agreement. Total payment made under this Agreement for the first year by City
shall be an amount not to exceed Fifty Thousand Dollars and Zero Cents ($50,000.00). 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 June 30, 2024 in line with the cooperative contract.
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:
City of Fort Worth
Attn: Fernando Costa, Assistant City Manager
200 Texas Street
Fort Worth, TX 76102-6314
Facsimile: (817) 392-8654
With copy to Fort Worth City Attorney's Office
at same address
To VENDOR:
A.W. Chesterton Company
Attn.: Ben Wittreich, VP Sales -North America
860 Salem St.,
Groveland, MA 01834
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:
By:
Name: Fernando Costa
Title: Assistant City Manager
Date: Apr 4, 2024
APPROVAL RECOMMENDED:
C>Cares� H"deP
By: Christopher Harder (Apr 2, 202412:51 CDT)
Name: Christopher Harder
Title: Water Director
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ATTEST:
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nEXa?oQp
By:
Name: Jannette S. Goodall
Title: City Secretary
VENDOR:
A.W. Chesterton Company
(Ma128,202411:40 EDT)
By: BenjamiE(Wittreich
Name: Ben Wittreich
Title: VP Sales -North America
Date: M a r 28, 2024
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:
s� a�
Name: Shatabya Bergland
Title: Contract Compliance Specialist
APPROVED AS TO FORM AND LEGALITY:
Qaee.;�.tL GlJ
By: QO
Name: Jessika Williams
Title: Assistant City Attorney
CONTRACT AUTHORIZATION:
M&C: N/A
OFFICIAL RECORD
CITY SECRETARY
FT. WORTH, TX
(1n9k._
CHESTERTON�
Global Solutions, Local Service.
Customer No
FORT WORTH WASTE WATER
1500 11TH AVENUE
Fort Worth, TX 76102
United States
EXHIBIT A
A.W. CHESTERTON COMPANY
WORLDWIDE HEADQUARTERS
860 SALEM ST.
GROVELAND, MA. 01834 U.S.A
PHONE (781) 438-7000 FAX (781) 481-2500
http.-Ilwww.chesterton.com
Quotation
Q002103981-7
Local Service Center :
Paqe
Quotation Date
Expiration Date
Sales Person
Our Reference
Customer Reference
A.W.Chesterton Company
North Louisiana Service Center
4500 MARLENA STREET
BOSSIER CITY, LA. 71111
Fax (318) 869-8930
Tel (318) 869-6232
1 of 1
2/28/2024
4/6/2024
Barry Huffman - Specialist -
Shreveport
Stevens Rachel
Customer Requsition
Line
Item number
Description Quantity
Unit Sales price
1.0
687478
442 -44 SA RSC/RSC S FKM 4.00
ea 10,150.70
- LEAD TIME IS 5-7 BUSINESS DAYS PLUS SHIPPING ARO -
2.0
XXXXXX
F16500RS8000(ESC) 2.00
ea 1,639.00
Split, Axial length of 1.850"
Right (CW) SpiralTrac
Item #: TBD ARO
3.0
XXXXXX
F16500LS8000(ESC) 2.00
ea 1,639.00
Split, Axial length of 1.850"
Left (CW) SpiralTrac
ITEM #: TBD ARO
- LINE 2 AND 3 HAVE A LEAD TIME OF 2-3 BUSINESS WEEKS PLUS SHIPPING ARO -
BUYBOARD CONTRACT #: 672-22
DISCOUNT OF 5% HAS BEEN ADDED TO THIS QUOTE.
JOSE GARCIA
QUOTE
Extended
40,602.80
3,278.00
3,278.00
Mode of delivery
Delivery terms
Payment terms
Delivery address FORT WORTH WASTE WATER
1500 11TH AVENUE Fort Worth, TX 76102 United States
Currency Amount Charges Sales tax amount Total
U S D 47,158.80 0.00 0,00 47,158.80
The pricing and lead time in this quote shall remain effective for thirty (30) days from the date of issuance.
THIS QUOTATION CONSTITUTES AN OFFER OF SALE. CHESTERTON'S ACCEPTANCE OF ANY ORDER IS EXPRESSLY LIMITED TO CUSTOMER'S ACCEPTANCE OF
CHESTERTON'S GENERAL TERMS AND CONDITIONS OF SALE, AVAILBALE THROUGH THE BELOW HYPERLINK OR YOUR CHESTERTON REPRESENTATIVE, WHICH CANNOT
BE ALTERED OR AMENDED WITHOUT CHESTERTON'S EXPRESS WRITTEN CONSENT. CHESTERTON OBJECTS TO ANY DIFFERENT OR ADDITIONAL TERMS. ANY ACT BY
CHESTERTON IN MANUFACTURING OR DELIVERING ANY PRODUCTS/ITEMS OR INITIATING OR PERFORMING ANY SERVICES FOR OR TO CUSTOMER SHALL NOT
CONSTITUTE AN ACCEPTANCE OF ADDITIONAL OR DIFFERENT TERMS IN CUSTOMER'S PURCHASE ORDER OR ANY OTHER DOCUMENT.
Chesterton General Terms and Conditions of Sale
THESE ITEMS ARE CONTROLLED BY THE U.S. GOVERNMENT AND AUTHORIZED FOR EXPORT ONLY TO THE COUNTRY OF ULTIMATE DESTINATION FOR USE BY THE
ULTIMATE CONSIGNEE OR END-USER(S) HEREIN IDENTIFIED. THEY MAY NOT BE RESOLD, TRANSFERRED, OR OTHERWISE DISPOSED OF, TO ANY OTHER COUNTRY OR
TO ANY PERSON OTHER THAN THE AUTHORIZED ULTIMATE CONSIGNEE OR END-USER(S), EITHER IN THEIR ORIGINAL FORM OR AFTER BEING INCORPORATED INTO
OTHER ITEMS, WITHOUT FIRST OBTAINING APPROVAL FROM THE U.S. GOVERNMENT OR AS OTHERWISE AUTHORIZED BY U.S. LAW AND REGULATIONS.
NO PRODUCT MAY BE RETURNED TO US FOR CREDIT EXCEPT UPON WRITTEN AUTHORITY
ALL MERCHANDISE PRODUCED BY UN IN ACCORDANCE WITH U.S. FAIR LABOR STANDARDS ACT OF 1938 AS AMENDED
EXHIBIT B
DVBoard°
4/27/2022
Sent Via Email:Trent.Elizondo@chesterton.com
Trent Elizondo
A W Chesterton
5808 Genoa Red Bluff
Pasadena, Texas 77507
Welcome to BuyBoard!
P.O. Box 400, Austin, Texas 78767
800.695.2919 • info@buyboard.com • buyboard.com
Re: Notice of The Local Government Purchasing Cooperative ContractAward; Proposal Invitation No. 672-
22, Water and Wastewater Pumps and Motors
Congratulations, The Local Government Purchasing Cooperative (Cooperative) has awarded your company
a BuyBoard® contract based on the above -referenced Proposal Invitation. The contract is effective for an
initial one-year term of July 1, 2022 through June 30, 2023, and may be subject to two possible one-year
renewals. Please refer to the Proposal Invitation for the contract documents, including the General Terms
and Conditions of the Contract.
To review the items your company has been awarded, please review Proposal Tabulation No. 672-22 at:
www.buyboard.com/vendor. Only items marked as awarded to your company are included in this contract
award, and only those awarded items may be sold through the BuyBoard contract. All sales must comply
with the contract terms and must be at or below the awarded pricing as set forth in the General Terms and
Conditions.
The contract will be posted on the BuyBoard website as an online electronic catalog(s). You are reminded
that, in accordance with the General Terms and Conditions, all purchase orders must be
processed through the BuyBoard. Except as expressly authorized in writing by the Cooperative's
administrator, you are not authorized to process a purchase order received directly from a Cooperative
member that has not been processed through the BuyBoard or provided to the Cooperative. If you receive
a purchase order directly from a Cooperative member that you have reason to believe has not been received
by the Cooperative or processed through the BuyBoard, you must promptly forward a copy of the purchase
order by email to info@buyboard.com.
A list of Cooperative members is available on the buyboard.com website. The BuyBoard vendor relations
staff will be contacting you to assist with the resources available and to provide any support you may need
as an awarded BuyBoard vendor.
On behalf of the Cooperative, 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 (select option "2").
Sincerely,
Arturo Salinas
Asst. Division Director, Cooperative Purchasing
Texas Association of School Boards, Inc.,
Administrator for The Local Government Purchasing Cooperative
v.02.01.2021
Endorsed by A TASAV VT
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URCNASINQ COOPERATIVE
12007 Research Boulevard • Austln, Texas 78759-2439 PH; 800-695-2919 • buvboard.com
PROPOSER'S ACCEPTANCE AND AGREEMENT
Proposal Invitation Name: Water and
Wastewater Pumps and Motors
Proposal Invitation Number: 672-22
Contract Term. July 1, 2022, through June 30,
2023, with two possible one-year renewals.
Proposal Due Date/Openina Date and Time:
January 20, 202-2, at 4:00 PM
Location of Proposal Oneninal:
Texas Association of School Boards, Inc.
BuyBoard Department
12007 Research Blvd.
Austin, TX 78759
Anticipated Cooperative Board Meetina Date:
April 2022
By signature below, the undersigned acknowledges and agrees that you are authorized to submit this
Proposal, including making all acknowledgements, consents, and certifications herein, on behalf of Proposer
and, to the best ofyour knowledge, the Information provided Is true, accurate, and complete,
AW Chesterton Company
Name of Proposing Company
5808 Genoa -Red Bluff Rd
Street Address
Pasadena, TX 77505
City, State, Zip
817-773-1187
Telephone Number of Authorized Company Official
1 /18/2022
Date
117
Signature of Authorized Company Official
Trent Elizondo
Printed Name of Authorized Company Official
Area Manager
Position or Title of Authorized Company Official
04-1173400
Fax Number of Authorized company official Federal ID Number
Page 10 of 71
Proposal Forms COMM/Svcs VM.11,2021
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PiiRC1tA51NC CflOPERA7f Vf
12007 Research Boulevard , Austin, Texas 78759-2439 , PH: 800-695-2919 ` buvboard.com
PROPOSAL FORMS PART 1: COMPLIANCE FORMS
INSTRUCTIONS:
Proposer must review and complete all forms in this Proposal Forms Part 1:
■ Proposal Acknowledgements
■ Felony Conviction Disclosure
• Resident/Nonresldent Certification
• Debarment Certificatlon
■ Vendor Employment Certification
• No Boycott Verification
• No Excluded Nation or Foreign Terrorist Organization Certiflcation
• Historically Underutilized Business Certification
• Acknowledgement of BuyBoard Technical Requirements
• Construction -Related Goods and Services Affirmation
■ Deviation and Compliance
• Vendor Consent for Name Brand Use
■ Confidential/Proprietary Information
■ EDGAR Vendor Certification
• Compliance Forms Signature Page
An authorized representative of Proposer must initial in the bottom right corner of each Pacie where indicated
and complete and sign the Compliance Forms Signature Page. Proposers failure to fully complete, initial, and
sign forms as required may result in your Proposal being rejected as non -responsive.
PROPOSAL ACKNOWLEDGEMENTS
The proposing company ("you" or "your") hereby acknowledges and agrees as follows:
1. You have carefully examined and understand all information and documentation associated with this Proposal Invitation,
Including the Instructions to Proposers, General Information, General Terms and Conditions, attachments/forms,
appendices, item specifications, and line items (collectively "Requirements'o;
2. By your response ('Proposal') to this Proposal Invitation, you propose to supply the products or services submitted at
the pricing quoted In your Proposal and in strict compliance with the Requirements, unless specific deviations or
exceptions are noted In the Proposal;
3. By your Proposal, you acknowledge and certify all items set forth in the General Terms and Conditions, Section B.12
(Certifications), including all non -collusion certifications and certifications regarding legal, ethical, and other matters set
forth therein.
4. Any and all deviations and exceptions to the Requirements have been noted in your Proposal on the required form and
no others will be claimed;
Page 11 of 71
ProQosal i=0rlil5 COhiMINCS v,04.l1.2021
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Wt1RCNASINO C60PERA7IVE
12007 Research Boulevard ' Austin, Texas 78759-2439 ' PH: 800-695-2919 ' lawboard.com
5. If the Cooperative accepts any part of your Proposal and awards you a Contract, you will furnish all awarded products or
services at the pricing quoted and in strict compliance with the Requirements (unless specific deviations or exceptions
are noted on the required form and accepted by the Cooperative), Including without limitation the Requirements related
to:
a, conducting business with Cooperative members, Including offering pricing to members that Is the best you offer
compared to similarly situated customers in similar circumstances;
b, payment of a service fee in the amount specified and as provided for In this Proposal Invitation;
c. the possible award of a piggy -back contract by the National Purchasing Cooperative or nonprofit entity, In which
event you will offer the awarded products and services in accordance with the Requirements; and
d, submitting price sheets or catalogs in the proper format as required by the Cooperative as a prerequisite to activation
of your Contract;
6. You have clearly Identified on the included form any Information in your Proposal that you believe to be confidential or
proprietary or that you do not consider to be public information subject to public disclosure under the Texas Public
Information Act or similar public Information law;
7. The individual submitting this Proposal is duly authorized to enter into the contractual relationship represented by this
Proposal Invitation on your behalf and bind you to the Requirements, and such individual (and any individual signing a
form or Proposal document) is authorized and has the requisite knowledge to provide the Information and make the
representations and certifications required in the Requirements;
8. You have carefully reviewed your Proposal, and certify that all Information provided is true, complete, and accurate to
the best of your knowledge, and you authorize the Cooperative to take such action as it deems appropriate to verify such
information; and
9. Any misstatement, falsification, or omission in your Proposal, whenever or however discovered, will be grounds for
disqualifying you from consideration for a contract award under this Proposal Invitation, termination of a contract award,
or any other remedy or action provided for in the General Terms and Conditions or by law.
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 W) one of the following:
❑ My company is a publicly -held corporation. (Advance notice requirement does not apply to publicly -held corporation.)
0 My company is not owned or operated by anyone who has been convicted of a felony.
❑ My company is owned operated by the following individuals) who has/have been convicted of a felony:
Name of Felon(s):
Details of Convlction(s):
Page 12 oP 71
Proposal Forms Commisvcs v,og.n.2on
46
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I Ward'
NCHASIHO COOPERATIVE
12007 Research Boulevard ' Austin, Texas 78759-2439 PH: 800-695-2919 1 buvboard.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 NI one of the followina:
❑ I certify that my company is a Resident Proposer.
W 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);
AW Chesterton Company 860 Salem Street
Company Name
Groveland
city .
Address
MA 01834
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 Q No
B. What is the prescribed amount or percentage? $
or
DEBARMENT CERTIFICATION
By signature on the Compliance Forms Signature Page, I certify that neither my company nor an owner or principal of my
company has been debarred, suspended or otherwise made Ineligible for parucipatlon 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.
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 (€) 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 W) one of the followina:
❑ Yes F,,] No
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Proposal FOmu COMMlSt1C5 v.06.11,2021
12007 Research Boulevard ' Austin, Texas 78759-2439 - PH: 800-695-2919 , buvboard.com
NO BOYCOTT VERIFICATION
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 will
not boycott Israel during the term of the contract (TEX. Gov`T CODE Ch, 2271), (2) does not boycott energy companies and
will not boycott energy companies during the term of the contract (TEX, Gov'T CODE Ch. 2274 effective September 1, 2021),
and (3) does not have a practice, policy, guidance, or directive that discriminates against a firearm entity or firearm trade
association and will not discriminate during the term of the contract against a firearm entity or firearm trade association (TEX.
Gov'T CODE Ch. 2274 effective September 1, 2021). 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).
"Boycott energy company" means, without an ordinary business purpose, 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 with
a company because the company: (A) engages in the exploration, production, utilization, transportation, sale, or
manufacturing of fossil fuel -based energy and does not commit or pledge to meet environmental standards beyond applicable
federal and state law; or (B) does business with a company described by Paragraph (A), TEX, Gov'T CODE §809.001(1)
(effective September 1, 2021).
"Discriminate against a firearm entity or firearm trade association" means, (A) with respect to the entity or association, to:
(1) refuse to engage in the trade of any goods or services with the entity or association based solely on its status as a firearm
entity or firearm trade association; (ii) refrain from continuing an existing business relationship with the entity or association
based solely on its status as a firearm entity or firearm trade association; or (iii) terminate an existing business relationship
with the entity or association based solely on its status as a firearm entity or firearm trade association; and (B) does not
include: (i) the established policies of a merchant, retail seller, or platform that restrict or prohibit the listing or selling of
ammunition, firearms, or firearm accessories; and (il) a company's refusal to engage in the trade of any goods or services,
decision to refrain from continuing an existing business relationship, or decision to terminate an existing business relationship:
(aa) to comply with federal, state, or local law, policy, or regulations or a directive by a regulatory agency; or (bb) for any
traditional business reason that is specific to the customer or potential customer and not based solely on an entity's or
association's status as a firearm entity or firearm trade association. TEX. Gov'T CODE §2274.001(3) (effective September 1,
2021).
By signature on the Compliance Forms Signature Page, to the extent applicable, I certify and verify that Vendor does not
boycott Israel, boycott energy companies, or discriminate against a firearm entity or firearm trade association and will not
do so 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.
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Proposal Forms COMWSVCS v.08.11.2021
PFURC1fAS1Ni1 COOPERATIVE
12007 Research Boulevard ' Austin, Texas 78759-2439 • PH: 800-695-2919 , buvboard.com
NO EXCLUDED NATION OR FOREIGN TERRORIST ORGANIZATION CERTIFICATION.
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 on the Compliance Forms Signature Page, 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.
HISTORICALLY UNDERUTILIZED BUSINESS 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 BuyBoard website will indicate HUB certifications for awarded Vendors that
properly indicate and document their HUB certification on this form. Please check i,/l all that anoly:
❑ 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:
Name of Certifying Agency:
0 My company has NOT been certified as a HUB.
ACKNOWLEDGEMENT OF BUYBOARD TECHNICAL REOUIREMENTS
Vendor shall review the BuyBoard Technical Requirements included in this Proposal Invitation. By signature on the Compliance
Forms Signature Page, the undersigned affirms that Proposer has obtained a copy of the BuyBoard Technical Requirements,
has read and understands the requirements, and certifies that Vendor is able to meet and will comply with those requirements
except as follows; [List and explain BuyBoard Technical Requirements, If any, to which your company cannot or will g_ot
comply.]
Mote: In accordance with the General Terms and Conditions of the Contract, to the extent Vendor is awarded a Contract
under this Proposal Invitation but is unable or unwilling to meet the applicable BuyBoard Technical Requirements, the
Information available on the BuyBoard for Vendor's awarded products or services may be limited, potentially placing Vendor
at a disadvantage and impacting the ability of Cooperative members to search, find, review, and purchase Vendor's awarded
products and services on the BuyBoard website. Further, to the extent Vendor has acknowledged ability to meet and comply
with the BuyBoard Technical Requirements, any subsequent failure or refusal by Vendor to promptly provide information
upon request to the Cooperative administrator in accordance with those technical requirements may be deemed an a of
default under the Contract. Initial: an
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URCiIASING COOPERANVE
12-007 Research Boulevard • Austin, Texas 78759-2439 - PH, 800-695-2.919 buvboard.corn
CONSTRUCTION -RELATED GOODS AND SERMicES AEiFIRI+►#A7ION
The Cooperative issued the BuyBoard Procurement and Constructlon-Related Goods and Services Advisory for Texas Members
("Advisory'% which provides information specifically relevant to the procurement of construction -related goods and services
by Texas Cooperative members. The Advisory, available at buvboard.com/Vendor/Resources.asox, 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, Because many BuyBoard contracts
include goods or installation services that might be considered construction -related, Proposer must make this Construction
Related -Goods and Services Affirmation regardless of type of goods or services associated with this Proposal Invitation.
A contract awarded under this Proposal invitation covers only the specific goods and/or services awarded by the Cooperative,
As explained In the Advisory ("Advisory'l, Texas law prohibits the procurement of architecture or engineering
services through a purchasing cooperative. This Proposal Invitation and any Contract awarded thereunder
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. ,
By signature on the Compliance Forms Signature Page, Proposer 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 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 accepting the member's Purchase Order or other agreement for construction -related goods or
services.
IfftkMIM
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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. Prior to completing this form, Vendor
shall review the General Terms and Conditions section B.4 (Deviations from Item Specifications and General
Terms and Conditions). Please note that, as provided In section 5.4, certain provisions of the General Terms
and Conditions are NOT subject to deviation, and certain deviations will be deemed rejected without further
action by the Cooperative. Any attempted deviation, whether directly or Indirectly, to provisions identified in
this Proposal Invitation as not subject to deviation shall be deemed rejected by the Cooperative and, unless
otherwise withdrawn by Vendor, may result in Vendor's Proposal being rejected in its entirety.
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, by and through the Cooperative administrator, 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 C0 one of the foilowina:
0 No; Deviations
❑ Yes; Deviations
List and fully explain any deviations you are submitting:
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BuyBoard members seeking to make purchases using a Contract awarded under this Proposal Invitation may view information
regarding awarded Vendors, including but not limited to product catalogs, pricelists, pricing, and Proposals, through the
BuyBoard website. To improve and enhance the experience of BuyBoard members seeking to procure goods and services
under the Contract utilizing the BuyBoard website, any Vendor Ibgo, product images, and similar brand and trademark
Information provided by Vendor for purposes of the Contract ("Vend6r Information") may be posted on the BuyBoard website,
You acknowledge that, by submitting your Proposal, unlesslyou specifically opt out below, you consent to use
of your company's Vendor Information on the BuyBoard we�site if awarded a Contract. You further acknowledge
that whether, where, and when to include the Vendor Information on the BuyBoard website shall be at the sole discretion of
the BuyBoard Administrator. Vendor retains, however, the right of general quality control over the BuyBoard Administrator's
authorized display of proprietary Vendor Information. Neither the BuyBoard nor Its administrator will be responsible for the
use or distribution of Vendor Information by BuyBoard members or any other third parry using the BuyBoard website. This
Vendor Consent shall be effective for the full term of the Contract, including renewals, unless Vendor provides a signed,
written notice revoking consent to contractadmiri(Obuvboard.com. 'BuyBoard shall have up to thirty days from the date of
receipt of a termination or revocation of a Vendor Consent to remove Vendor information from the BuyBoard website.
This Vendor Consent is subject to the Terms and Conditions of the Contract, including, but not limited to, those terms
pertaining to Disclaimer of Warranty and Limitation of Liability, Indemniflcation, and Intellectual Property Infringement.
Vendor logo files must be submitted in one of the formats set forth in the BuyBoard Technical Requirements. Proposers are
requested to submit this information with Vendor's Proposal. (This consent shall not authorize use of your company's Vendor
Information by BuyBoard if your company is not awarded a Contract.)
OPT OUT:
If your company wishes to opt out of the Vendor Consent for Name Brand Use, you must check the opt out box below. DO
NOTselect this box unless your company is opting out of tiffs Vendor Consent for Name Brand Use.
❑ By checking this box, Vendor hereby declines to provide consent for use of Vendor Information (as defined herein) on
the BuyBoard website, By opting out, Vendor acknowledges and agrees that, if Vendor Is awarded a Contract
under this Proposal Invitation, Information available on the BuyBoard for Vendor's awarded products or
services may be limited, potentially placing Vendor at a disadvantage and impacting the ability of
Cooperative members to search, find, review, and purcha$e Vendor's awarded products and services on the
BuyBoard website
rM
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CONFIDENTIAL/PROPRIETARY INFORMATION
A. Public Disclosure laws
All Proposals, forms, documentation, catalogs, pricellsts, or other materials submitted by Vendor to the Cooperative in
response to this Proposal Invitation, 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 falls 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 party request access to the Information under the Texas Public Information Act or similar disclosure law. When
required by the Texas Public Information Act or other disclosure law, Proposer may 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, catalogs, pricelists, or other materials submitted with the Proposal)
contain information which Vendor considers proprietary or confidential?
Please check N1 one of the followina:
MNO, 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 clearly 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 Cooperative administrator shall 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 Cooperative
administrator will disclose information when required by law, even if such information has been identified herein as
Information Vendor considers confidential or proprietary.
Confidential / Proprietary Information:
(Attach addltlonal sheets Kneeded.)
Initial:���
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B. CoDvriaht Information
Does your Proposal (including forms, documentation, pricelists, catalogs, or other materials submitted with the Proposal)
contain copyright information?
Please check (,/) one of the rollowino!
QNO, Proposal (including forms, documentation, pricellsts, catalogs, or other materials submitted with the Proposal) does not
contain copyright information.
❑ YES, Proposal (including forms, documentation, pricelists, catalogs, or other materials submitted with the Proposal) does
contain copyright information.
If you responded "YES', clearly Identify below the specific documents or pages containing copyright information.
Copyright information:
(Attach additional sheets if needed.)
C. Consent to Release Confidential/Prourietarv/Conyd ht Informatt9m to BuvBoard 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 Cooperative administrator will
be responsible for the use or distribution of Information by BuyBoard members or any other parry.
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 publicly release, Including posting on the public
BuyBoard website, a copy of the proposal tabulation and award information for the Contract Including Vendor name; proposed
catalog/pricelist name(s); proposed percentage discount(s), hourly labor rate(s), or other specified pricing; and Vendor award
or non -award Information.
Initial:
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EDGAR VENDOR CERTIFICATION
(2 CFR part 200 and Appendix II)
When a Cooperative member seeks to procure goods and services using funds under a federal grant or contract, specific
federal laws, regulations, and requirements may apply in addition to those under state law. This Includes, but is not limited
to, the procurement standards of the Uniform Administrative Requirements, Cost Principles and Audit Requirements for
Federal Awards, 2 CFR 200 (sometimes referred to as the "Uniform Guidance" or new "EDGAR`l. All Vendors submitting a
Proposal must complete this EDGAR Certification Form regarding Vendor's willingness and ability to comply with certain
requirements which may be applicable to specific Cooperative member purchases using federal grant funds. Completed
forms will be.made available to Cooperative members for their use while considering their purchasing options when using
federal grant funds. Cooperative members may also require Vendors to enter Into ancillary agreements, In addition to the
terms and conditions of the BuyBoard contract, to address the member's specific contractual needs, including contract
requirements for a procurement using federal grants or contracts.
For eachof the items below, Vendor should certify Vendor's agreement and ability to comply, where
applicable, by having Vendor's authorized representative check the applicable boxes, Initial each page, and
sign the Compliance Forms Signature Page, If you fall to complete any Item In this form, the Cooperative will
consider and may list the Vendor's response on the BuyBoard as "No, ','the Vendor Is unable or unw1111ng to
comply, A "NO" response to any of the Items may, If applicable, impact the ability of a Cooperative member to purchase
from the Vendor using federal funds,
1. Vendor Violation or Breach of Contract Terms:
Contracts for more than the simplified acquisition threshold, which is the inflation adjusted amount determined by the Civilian
Agency Acquisition Council and the Defense Acquisition Regulations Council (Councils) as authorized by 41 U5C 1908, must
address administrative, contractual, or legal remedies in Instances where contractors violate or breach contract terms, and
provide for such sanctions and penalties as appropriate,
Provisions regarding Vendor default are included in the BuyBoard General Terms and Conditions, Including Section E,18,
Remedies for Default and Termination of Contract. Any Contract award will be subject to such BuyBoard General Terms and
Conditions, as well as any additional terms and conditions In any Purchase Order or Cooperative member ancillary contract
agreed upon by Vendor and the Cooperative member which must be consistent with and protect the Cooperative member at
least to the same extent as the BuyBoard Terms and Conditions. The remedies under the Contract are in addition to any
other remedies that may be available under law or in equity. By submitting a Proposal, you agree to these Vendor violation
and breach of contract terms.
A YES, I agree. ❑ NO, I do not agree.
2. Termination for Cause or Convenience:
For any Cooperative member purchase or contract in excess of $10,000 made using federal funds, you agree that the following
term and condition shall apply:
The Cooperative member may terminate or cancel any Purchase Order under this Contract at any time, with or without cause,
by providing seven (7) business days advance written notice to the Vendor. If this Agreement is terminated in accordance
with this Paragraph, the Cooperative member shall only be required to pay Vendor for goads or services delivered to the
Cooperative member prior to the terminatlon and not otherwise returned in accordance with Vendor's return pollcy. If the
Cooperative member has paid Vendor for goods or services not yet provided as of the date of termination, Vendor shall
immediately refund such payment(s),
If an alternate provision for termination of a Cooperative member purchase for cause and convenience, including the manner
by which it will be effected and the basis for settlement, is included in the Cooperative member's Purchase Order or ancillary
agreement agreed to by the Vendor, the Cooperative member's provision shall control.
A YES, I agree. ❑ NO, I do not agree, initial.
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3. Equal Employment Opportunity:
Except as otherwise provided under 41 CFR Part 60, all Cooperative member purchases or contracts that meet the definition
of "federally assisted construction'contract" in 41 CFR Part 60-1.3 shall be deemed to Include the equal opportunity clause
provided under 41 CFR 60-1.4(b), in accordance with Executive Order 11246, "Equal Employment Opportunity" (30 FR 12319,
12935, 3 CFR Part, 1964-1965 Camp,, p. 339), as amended by Executive Order 11375, "Amending Executive Order 11246
Relating to Equal Employment Opportunity," and implementing regulations at 41 CFR Part 60, "Office of Federal Contract
Compliance Programs, Equal Employment Opportunity, Department of Labor,"
The equal opportunity clause provided under 41 CFR 60-1,4(b) Is hereby incorporated by reference. Vendor agrees that such
provision applies to any Cooperative member purchase or contract that meets the definition of "federally assisted construction
contract" in 41 CFR Part 60-13 and Vendor agrees that it shall comply with such provision,
A YES, I agree. ❑ NO, I do not agree.
4. Davis -Baton Act:
When required by Federal program legislation, Vendor agrees that, for all Cooperative member prime construction
contracts/purchases in excess of $2,000, Vendor shall comply with the Davis -Bacon Act (40 USC 3141-3144, and 3146-3148)
as supplemented by Department of Labor regulations (29 CFR Part 5, "Labor Standards Provisions Applicable to Contracts
Covering Federally Financed and Assisted Construction"). In accordance wlth the statute, Vendor Is required to pay wages to
laborers and mechanics at a rate not less than the prevailing wages specified in a wage determinate made by the Secretary
of Labor. In addition, Vendor shall pay wages not less than once a week.
Current prevailing wage determinations issued by the Department of Labor are available at beta.sam.gov. Vendor agrees
that, for any purchase to which this requirement applies, the award of the purchase to the Vendor is conditioned upon
Vendor's acceptance of the wage determination.
Vendor further agrees that it shall also comply with th6 Copeland "Anti -Kickback" Act (40 USC 3145), as supplemented by
Department of Labor regulations (29 CFR Part 3, "Contractors and Subcontractors on Public Building or Public Work Financed
in Whole or In Part by Loans or Grants from the United States"). The Act provides that each contractor or subrecipient must
be prohibited from inducing, by any means, any person employed In the construction,'completion, or repair of public work,
to give up any part of the compensation to which he or she Is otherwise entitled,
19 YES, I agree. ❑ NO, I do not agree.
S. Contract Work Hours and Safety Standards Act:
Where applicable, for all Cooperative member contracts or purchases In excess of $100,000 that involve the employment of
mechanics or laborers, Vendor agrees to comply with 40 USC 3702 and 3704, as supplemented by Department of Labor
regulations (29 CFR Part 5), Under 40 USC 3702 of the Act, Vendor is required to compute the wages of every mechanic and
laborer on the basis of a standard work week of 40 hours. Work in excess of the standard work week is permissible provided
that the worker is compensated at a rate of not less than one and a half times the basic rate of pay for all hours worked in
excess of 40 hours in the work week,
The requirements of 40 USC 3704 are applicable to construction work and provide that no laborer or mechanic must be
required to work in surroundings or under working conditions which are unsanitary, hazardous or dangerous. These
requirements do not apply to the purchases of supplies or materials or articles ordinarily available on the open market, or
contracts for transportation or transmission of Intelligence.
19 YES, I agree. ❑ NO, I do not agree.
Initial: AO�
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6. Right to Inventions Made Under a Contract or Agreement.,
If the Cooperative member's Federal award meets the definition of "funding agreement" under 37 CFR 401.2(a) and the
recipient or subrecipient wishes to enter into a contract with a small business firm or nonprofit organization regarding the
substitution of parties, assignment or performance or experimental, developmental, or research work under that "funding
agreement," the recipient or subrecipient must comply with the requirements of 37 CFR Part 401, "Rights to Inventions Made
by Nonprofit Organizations and' Small Business Firms Under Government Grants, Contracts and Cooperative Agreements,"
and any Implementing regulations issued by the awarding agency.
Vendor agrees to comply with the above requirements when applicable.
❑ YES, I agree. 11 1 NO; I do not agree.
7. Clean Air Act and Federal Water Pollution Control Act:
Clean Air Act (42 USC 7401-7671q.) and the Federal Water Pollution Control Act (33 USC 1251-1387), as amended — Contracts
and subgrants of amounts in excess of $150,000 must contain a provision that requires the non -Federal award to agree to
comply with all applicable standards, orders, or regulations issued pursuant to the Clean Air Act (42 USC 7401-7671q.) and
the Federal Water Pollution Control Act, as amended (33 USC 1251-1387). Violations must be reported to the Federal
awarding agency and the Regional Office of the Environmental Protection Agency (EPA).
When required, Vendor agrees to comply with all applicable standards, orders, or regulations issued pursuant to the Clean
Air Act and the Federal Water Pollution Control Act.
A YES, I agree. ❑ NO, I do not agree.
8. Debarment and Suspension:
Debarment and Suspension (Executive Orders 12549 and 12689) — A contract award (see 2 CFR 180.220) must not be made
to parties listed on the government -wide exclusions In the System for Award Management (SAM), In accordance with the
OMB guidelines at 2 CFR 180 that implement Executive Orders 12549 (3 CFR Part 1966 Comp. p. 189) and 12689 (3 CFR
Part 1989 Comp. p. 235), "Debarment and Suspension." SAM Exclusions contains the names of parties debarred, suspended,
or otherwise excluded by agencies, as well as parties declared ineligible under statutory or regulatory authority other than
Executive Order 12549.
Vendor certifies that Vendor is not currently listed on the government -wide exclusions in SAM, is not debarred, suspended,
or otherwise excluded by agencies or declared Inellgible under statutory or regulatory authority other than Executive Order
12549, Vendor further agrees to immediately notify the Cooperative and all Cooperative members with pending purchases or
seeking to purchase from Vendor if Vendor is later fisted on the government -wide exclusions In SAM, or Is debarred,
suspended, or otherwise excluded by agencies or declared ineligible under statutory or regulatory authority other than
Executive Order 12549,
11 YES, I agree. ❑ NO, I do not agree.
9. Byrd Anti -Lobbying Amendment:
Byrd Anti -Lobbying Amendment (31 USC 1352) - Vendors that apply or bid for an award exceeding $100,000 must file the
required certification. Each tier certifies to the tier above that it will not and has not used Federal appropriated funds to pay
any person or organization for influencing or attempting to influence an officer or employee of any agency, a member of
Congress, officer or employee of Congress, or an employee of a member of Congress In connection with obtaining any Federal
contract, grant or any other award covered by 31 USC 1352. Each tier must also disclose any lobbying with non -Federal funds
that takes place in connection with obtaining any Federal award. Such disclosures are forwarded from tier to tier up to the
non -Federal award. As applicable, Vendor agrees to file all certifications and disclosures required by, and otherwise comply
with, the Byrd Anti -Lobbying Amendment (31 USC 1352).
A YES, I agree. ❑ NO, I do not agree.
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10. Procurement of Recovered Materials:
For Cooperative member purchases utilizing Federal funds, Vendor agrees to comply with Section 6002 of the Solid Waste
Disposal Act, as amended by the Resource Conservation and Recovery Act where applicable and provide such Information
and certifications as a Cooperative member may require to confirm estimates and otherwise comply. The requirements of
Section 6002 Include procuring only items designated in guidelines of the Environmental Protection Agency (EPA) at 40 CFR
Part Z47 that contain the highest percentage of recovered materials practicable, consistent with maintaining a satisfactory
level of competition, where the purchase price of the item exceeds $10,000 or the value of the quantity acquired during the
preceding fiscal year exceeded $10,000; procuring solid waste management services in a manner that maximizes energy and
resource recovery, and establishing an affirmative procurement program for procurement of recovered materials Identified in
the EPA guidelines.
11 YES, I agree. ❑ NO, I do not agree.
11. Domestic Preferences for Procurements:
Where appropriate and consistent with law, 2 CFR §200.322 contains certain considerations for domestic preferences for
procurements which may be applicable to Cooperative members using federal funds. When required by a Cooperative
member, Vendor agrees to provide such information or certification as may reasonably be requested by the Cooperative
member regarding Vendor's products, including whether goods, products, or materials are produced In the United States.
A YES, I agree. ❑ NO, I do not agree.
12. Prohibition on Certain Telecommunications and Video Surveillance Services or Equipment
2 CFR §200.216 prohibits expending federal loan or grant funds to procure or obtain certain telecommunications and video
surveillance services or equipment. To the extent applicable and when required by a Cooperative member, Vendor agrees to
provide such information or certification as may reasonably be requested by the Cooperative member to confirm whether
any telecommunications or video surveillance services or equipment provided by Vendor is covered equipment or covered
services under 2 CFR §200.216.
A YES, I agree. ❑ NO, I do not agree,
13. Profit as a Separate Element of Price:
For purchases using federal funds in excess of the Simplified Acquisition Threshold, a Cooperative member may be required
to negotiate profit as a separate element of the price. See, 2 CFR 200.324(b). When required by a Cooperative member,
Vendor agrees to provide Information and negotiate with the Cooperative member regarding profit as a separate element of
the price for a particular purchase, However, Vendor agrees that the total price, including profit, charged by Vendor to the
Cooperative member shall not exceed the awarded pricing, Including any applicable discount, under Vendor's Cooperative
Contract,
IN YES, I agree. ❑ NO, I do not agree.
14. 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 such
requirements as may apply to a particular Cooperative member purchase or purchases including, but not limited to, applicable
recordkeeping and record retention requirements.
A YES, I agree. ❑ NO, I do not agree.
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COMPLIANCE FORMS SIGNATURE PAGE
By initialing pages and by signature below, I certify that I have reviewed the following forms; that the information provided
therein is true, complete, and accurate, and that I am authorized by my company to make all certifications, consents,
acknowledgements, and agreements contained herein;
• Proposal Acknowledgements
■ Felony Conviction Disclosure
• Debarment Certiflcation
• Resident/Nonresident Certification
■ Vendor Employment Certification
• No Boycott Verification
■ No Excluded Nation or Foreign Terrorist Organization Certification
■ Historically Underutilized Business Certification
■ Construction -Related Goods and Services Affirmation
Acknowledgement of BuyBoard Technical Requirements
• Deviation and Compliance
• Vendor Consent for Name Brand Use
• Confidential/Proprietary Information
■ EDGAR Vendor Certification
AW Chesterton Company
Company
Signature of Authorized Company Official
Ben Wttreich
Printed Name and Title
1/18/2022
Date
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PROPOSAL FORMS PART 2: VENDOR INFORMATION FORMS
INSTRUCTIONS:
Proposer must completely and accurately provide all information requested in the following Vendor Information Forms or
your Proposal may be rejected as non -responsive:
■ Vendor Business Name
■ Vendor Contact Information
• Federal and State/Purchasing Cooperative
Experience
■ Governmental References
Company Profile
Texas Regional Service Designation
d State Service Designation
■ National Purchasing Cooperative Vendor Award
Agreement (vendors serving outside Texas oniy)
• Local/Authorized Seller Listings
■ Manufacturer Dealer Designation
■ Proposal Invitation Questionnaire
• Vendor Request to Self -Report BuyBoard
Purchases (optional)
To the extent any information requested is not applicable to your company, you must so indicate on the form.
VENDOR BUSINESS NAME
By submitting a proposal, Vendor is seeking to enter into a legal contract with the Cooperative. As such, Vendor must be an
individual or legal business entity capable of entering Into a binding contract.
Name of Pr000sina Comnany:
(tilt the legal name of the company seeking to contract with the Cooperative. Po NOT list an 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 entityshould
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 W) one of the following;
Tvoe of Business: ❑ Individual/Sole Proprietor
❑ Other (Specify:
State of Incorporation (if applicable): MA
11 Corporation ❑ Limited Liability Company ❑ Partnership
Federal Emolover Identification Number: 04-1173400
(Vendor must include a completed IRS iN 9 form with their Proposal)
Name by which Vendor. if awarded. wishes to be identified on the BuvBoard. (Note. Ifdiflerentthan 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 Certifrcate(s), if
appllcable, must be attached.)
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Proposal Forms COMM/5VCS V.08.11.2021
Farm 9
Request for Taxpayer Give Form to the
(Rev. October2018) Identification Number and Certification requester. Do not
Department of the Treasury send to the IRS.
Internal Revenue Service ► Go to www_irs.gov/F`ormW9 for instructions and the latest information.
1 Name (as shown on your Income tax return). Name is required on this line; do not leave this line blank.
AW Chesterton Company
2 Business name/disregarded entity name, if different from above
M 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the 4 Exemptions (codes apply only to
0) following seven boxes. certain entitles, not individuals; see
a instructions on page 3):
o ❑ Individual/sole proprietor or ❑ C Corporation ❑✓ 3 Corporation ❑ Partnership ❑ Trust/estato
c single -member LLC Exempt payee code (if any)
u❑ Limited liability company. Enter the tax classification (CSC corporation, S=S corporation, P=Partnership) ►
o Note: Check the appropriate box in the line above for the tax classification of the single -member owner. Do not check Exemption from FATCA reporting
�' us LLC if the LLC is classified as a single -member LLC that is disregarded from the owner unless the owner of the LLC Is de (if any)
another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-membor LLC that co
IL u is disregarded from the owner should check the appropriate box for the tax classification of its owner.
❑ Other (see instructions)), (Applies to accounts maintained outside the U.S.)
cn 6 Address (number, street, and apt, or suite no,) See instructions. Requester's name and address (optional)
860 Salem St
6 City, state, and ZIP code
Groveland,MA 01834
7 List account number(s) here (optional)
Li: M Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid social security number
backup withholding. For individuals, this is generally your social security number (SSN). However, for a _ m
resident alien, sole proprietor, or disregarded entity, see the instructions for Part i, later. For other
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN, later. or
Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and I Employer identification number
Number To Give the Requester for guidelines on whose number to enter. MO4 -- I I
1 I 1 17 J 3 14 I O I tl
JEW 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 I 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, item 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 for Part 11, later.
Sign Signature at
Here U.S. person ► � � 7 Late ►
General Instructions • Form 1099-DIV (dividends, including those from stocks or mutual
funds)
Section references are to the Internal Revenue Code unless otherwise
noted.
Future developments. For the latest information about developments
related to Form W-9 and its instructions, such as legislation enacted
after they were published, go to www.irs.gov/FormW9.
Purpose of Form
An individual or entity (Form W-9 requester) who is required to file an
information return with the IRS must obtain your correct taxpayer
identification number (TIN) which may be your social security number
(SSN), individual taxpayer identification number (ITIN), adoption
taxpayer identification number (ATIN), or employer identification number
(EIN), to report on an information return the amount paid to you, or other
amount reportable on an information return. Examples of information
returns include, but are not limited to, the following.
• Form 1099-INT (interest earned or paid)
• Form 1099-MISC (various types of income, prizes, awards, or gross
proceeds)
• Form 1099-B (stock or mutual fund sales and certain other
transactions by brokers)
• Form 1099-S (proceeds from real estate transactions)
• Form 1099-K (merchant card and third party network transactions)
• Form 1098 (home mortgage interest), 1098-E (student loan interest),
1098-T (tuition)
• Form 1099-C (canceled debt)
• Form 1099-A (acquisition or abandonment of secured property)
Use Form W-9 only if you are a U.S. person (including a resident
alien), to provide your correct TIN.
if you do not return Form W-9 to the requester with a TIN, you might
be subject to backup withholding. See What is backup withholding,
later.
Cat. No. 10231X Form W-9 (Rev. 10-2018)
PURCt1ASINdard
12007 Research Boulevard ' Austin, Texas 78759-2439 • PH: 800-695-2919 ' buyboard,com
VENDOR CONTACT INFORMATION
Vendor shall provide the requested Vendor Contact information In the electronic proposal subm/sslon system
Including contract, purchase order, RFQ, and In volce contacts (or, IFsubm/tting a hard copy Proposal, timely
request and complete the Vendor Contactinformat/on form In accordance with the Instructlons to Proposers).
FEDERAL AND STATE/ PURCHASING COOPERATIVE EXPERIENCE
The Cooperative strives to provide Cooperative 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.
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: $0 . (The period of the 12-month
period is 1 ). 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,
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.
2. T-PASS (State of Texas)
3. OMNIA Partners
4. Sourcewell (NJPA)
5. E&I Cooperative
6. Houston -Galveston Area Council (HGAC)
7. Choice Partners
8. The Interiocal Purchasing System (TIPS)
9. Other
FW1 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 (%):
Exolanation: Not a current BUYBOARD Vendor
Page 27 of 71
Proposat Forms COMM/S/CS v.08.11.2021
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PURCNASINA COOPERATIVE
12007 Research Boulevard ' Austin, Texas 78759-2439 • PH: 800-695-2919 ' buvboard.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 pricing/discounts you offer each customer. The Cooperative may determine whether
pricing/discounts are fair and reasonable by comparing pricing/discounts stated in your Proposal with the pricing/discounts
you offer other governmental customers. Attach additional pages If necessary.
Quantity/
Entitv Name Contact Phone# Email Address Discount Volume
City of Auslin-- Davis WTP James Timmons 512-972-1766 james.Ummons@auslinlexas.gov 'No standard discount provided. Diswunis vary based on product line & application
2. San Antonio Water Systerns - Isabel Jimenez 210-233-3361 isabal.jimennz@saws.org 'No standard discount provided. Discounts vary based on product line & applicaton
3. Guadalupe Blanco RlverAuthority John hloryl 830-560-6199
4. TexasA&M University James Woodruff 979-862-7843
jmoryl@gbra.arg *No standard discount provided, Discounts vary based on product line & application
jamesvioodwff@lamL).edu 'No standard discount provided. discounts vary based on product line & application
City of Houston Kennelh Dement B32-309-2017 kennelh.demenl@houstontx.gov 'No slandard discount provided. Discounts vary based on product line & application
J.
Do you ever modify your written policies or standard governmental sales practices as identified in the above chart to give
better discounts (lower pricing) than indicated? YES ❑ NO K If YES, please explain:
COMPANY PROFILE
Information on awarded Cooperative Contracts is available to Cooperative Members on the BuyBoard website. If your
company is awarded a Contract under this Proposal Invitation, please provide a brief company description that you would
like to have included with your company profile on the BuyBoard website. Submit your company profile in a separate
file, in Word format, with your Proposal. (Note: Vendor Is solely responsible for any content provided for inclusion on
the BuyBoard website. The Cooperative reserves the right to exclude or remove any content in its sole discretion, with or
without prior notice, including but not limited to any content deemed by the Cooperative to be inappropriate, irrelevant to
the Contract, inaccurate, or misleading.)
Page 28 of 71
Proposal Forms COMMISVCS v,08,11,2021
CO�.'
CHESGloba�TER�TON:
Chesterton is a world leader in helping process industry companies and manufacturers improve
the reliability and efficiency of their rotating, stationary, and fluid power equipment platforms.
They are known across a wide range of industries for our award -winning pump and valve
sealing solutions, applications expertise, equipment maintenance and wear -prevention
products, and knowledgeable hands-on local service.
For over 130 years, they have spearheaded industry advances as part of their commitment to
help make their customers more profitable, more productive, and more environmentally
responsive. Their extensive experience and knowledge across the energy and process
industries makes them the go -to company for solving the most difficult sealing and equipment
reliability challenges.
Chesterton has over 450 sales and service locations in 113 countries. Their 1,200 factory -
trained local specialists and technicians are based around the globe and work closely with
customers in the field to help solve specific sealing and equipment reliability challenges. Their
large, established sales and service network includes more than 250 authorized distributors.
These distributors have extensive experience in the industries they serve and provide
exceptional local service and applications consulting.
Chesterton's state-of-the-art manufacturing equipment along with their global continuous -
improvement process enables them to drive productivity, efficiency, and quality throughout
their global facilities. By using lean tools and lean methodology, their world -class
manufacturing facilities deliver the highest quality products with the fastest delivery to their
customers. Chesterton strives for excellence in everything they do. They want their
manufacturing facilities to be the absolute best that they can possibly be to deliver high quality
products, services, and processes. Their unrelenting focus on operational excellence will drive
the future of Chesterton.
As part of our "Global Solutions, Local Service" philosophy, Chesterton maintains a retail &
service presence in Pasadena, Texas. The 30,000 square foot facility houses mechanical seal
repair, rotating equipment repair, engineering and sales teams. With a robust sales force,
product management and subject matter experts strategically located across Texas, Chesterton
is positioned to meet the needs of customers across the state.
A.W. Chesterton Company, 860 Salem Street, Groveland, Massachusetts 01834 USA • Tel: (978) 469-6446 Fax: (978) 469-6528 • www.chesterton.com
ruRerrasrNo eaaPeRnrrve
12007 Research Boulevard Austin, Texas 78759-2439 PH: 800-695-2919 ` buyboard.com
TEXAS REGIONAL SERVICE DESIGNATION
This form must be completed In the electronic proposal submission system Lo /f submlttlno a hard copy
ra osal tlmelvreauestand complete the form In accordance with the Instructions to Propose ,
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, in the electronic proposal submission system,
you must indicate if you will service Texas Cooperative members statewide or, if you do not plan to service all Texas
Cooperative members statewide, you must indicate the specific regions you will service. 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, (Additional forms can be obtained by contacting bidsC@buvboard.com at least five (5) business days Drior to
the Proposal Due Date.) By designating a region or regions, you are certifying that you are authorized and w1111ng
to provide the proposed products and services In those reglons Designating regions In which you are elther
unable or unwilling to pro vide the specified products and services shall be grounds for elther rejection of your
Proposal or, If awarded, termination of your Contract. Additionally, if you do not plan to service Texas Cooperative
members (i.e., if you will service only states other than Texas), you must so indicate on the form in the electronic DroDosal
submission system.
Regional Education Service Centers
Reallon and Headauarters
1
Edinburg
2
Corpus Christi
3
Victoria
4
Houston
5
Beaumont
b
Huntsville
7
Kilgore
8
Mount Pleasant
9
Wichita Falls
10
Richardson
11
Fort Worth
12
Waco
13
Austin
14 Abilene
15 San Angelo
15 Amarillo
17 Lubbock
18 Midland
19 El Paso
20 San Antonio
Page 29 of 71
Proposal Forms COMMISVCSv.08.f1,2021
err°
PURCfiASiNO COOPERATIVE
12007 Research Boulevard • Austin, Texas 78759-2439 , PH: 800-695-2919 FAX: 800-21t-5454 • buvboard.com
STATE SERVICE DESIGNATION
This form must he completed In the electronic proposal submisslon system for. If submlttlna a hard CODY
Proposal. timely reauest and complete the In accordance with the Instructlons to Proposers).
As set forth in the Proposal Invitation, it Is the Cooperative's intent that other governmental entities in the United States have
the opportunity to purchase goods or services awarded under the Contract, subject to applicable state law, through a piggy-
back award or similar agreement through the National Purchasing Cooperative BuyBoard. If you plan to service the entire
United States or only specific states, you must complete the State Service Desianation information in the electronic proposal
submission system. (Note: If you plan to service Texas Cooperative members, be sure that you complete the Texas Regional
Service Designation form.) In addition to this form, to be considered for a piggy -back award by the National
Purchasing Cooperat/ve, you must have an authorized representative sign the Natlonal Purchas/ng
Cooperative Vendor Award Agreement that follows this page.
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. (Additional forms can be obtained'by contacting bids@buvboard.com at least five (5) business
days prior to the Proposal Due Date.) By designating a state or states, you are certlfying that you are authorized
and willing to provide the proposed products and serv/ces in those states. Designating states in which you are
elther unable or unwilling to pro vide the speclfled products and services shall be grounds for elther rejectlon
of your Proposal or, if awarded, termination of your Contract.
• I will service all states in the United States.
• I will not service all states in the United States.
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
Kentucky
Texas
Louisiana
Utah
Maine
Vermont
Maryland
Virginia
Massachusetts
Washington
Michigan
West Virginia
Minnesota
Wisconsin
Mississippi
Wyoming
Missouri
Montana
Proposal Forms COMMIMS v.08.11.2021
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PURCNASINO COOAFRAVVE
12007 Research Boulevard • Austin, Texas 78759-2439 ft 800-695-2919 • FAX; 800-211-5454 ' buvhoard.com
NATIONAL PURCHASING COOPERATIVE VENDOR AWARD AGREEMENT
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") 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") 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,
5. 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,
vendor invoices, and/or such other documentation regarding those purchase orders as the Cooperative's administrators may
require in their reasonable discretion 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.
6. 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-proposal/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 COMM(SVCS v.08.11..2021
Page 31 of 71
oard
PURCHASIHO CROPCRArlVE
12007 Research Boulevard ' Austin. Texas 78759-2439 PH: 800-695-2919 • FAX: 800-211-5454 • buyhoard.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.
AW Chesterton Company
Name of a dor
Signature of Authorized Company Official
1 /18/2022
Date
672-22
Proposal Invitation Number
Ben Wittreich
Printed Name of Authorized Company Official
Proposal Forms COMM/SKS v.08,11.2021
Page 22 of 71
WBoard
URCNAS)NO COOPERATIVE
12007 Research Boulevard ' Austin, Texas 78759-2439 • PK 800-695-2919 ' FAX: 800-21 1-5454 • buyboard,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
Manufacturer Designated Dealer form.
Proposal Forms COMM/SVC5v.08,11,2021
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FtURCHASINDCOOPERAVVE
12007 Research Boulevard • Austin, Texas 78759-2439 , PK 800-695-2919 ' FAX; 800-211-5454 ` buvboard.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 subjectto 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 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. If you wish to designate multiple dealers, please duplicate this form as necessary.
Designated Dealer Name
Designated Dealer Address
City
Phone Number
Email address
Designated Dealer Contact Person
State Zip
Fax Number
Designated Dealer Tax ID Number* (*attach W-9)
Proposal Forms COMMIMS v.08.11.2D21
Page 34 of 71
®air
ruRcitasiuc coorsaArttrr
12007 Research Boulevard Austin, Texas 78759-2139 ' PH: 800-695-2919 ' FAX: 800-211-5454 ' buvbaard.cotn
PROPOSAL. INVITATION OUESTIONNAIRE
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"). 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 and submit in one
document with your Proposal. You must submit the questionnaire and responses with your Proposal or the
Proposal will not be 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,
In business since 1884 with the same name
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.
There are over 10 strategically located sales personnel responsible for supporting cusotrners
throughout Texas, Other resources include product managers, field service,and in-house appiicaiton engineering.
We also offer a 30K square foot Service Center and our Retail branch to provide local inventory and support for field sales.
Our field sales and product management teams have an average of 15 years of experience providing Industrial Sealing Solutions across industry.
3. Marketing Strateav; 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. tExamle: 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
term.)Attach additional pages if necessary.
We currently have a robust Sales Plan that includes targeted support and pursuit of business from current BuyBoard memebers.
We will continue to work closely with current cuslome€s and members as well as execute sirategle sales call activity to make new clients aware of our BuyBoard involvement
With our sales force siralegically placed in Southeast Texas, via can touch a broad geography across the stale and will specifically work to help large owners of pumps and pumping equlpmenl.
Proposal Forms COMM/SKS v,08.11,2021
Page 35 of 71
NUHRCHdStNC COt}PERh7JVE
i2007 Research Boulevard ' Austin, Texas 78759-2439 - PH: 800-695-2919 • FAX; 800-211-5454 ' buvboard,com
4. Describe Proposer's financial capabillty 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.
Chesterton is well positioned for supply of products in support of this contract.
The insurance coverage limits can be obtained to meet the requirements of the contract above and beyond current limits,
5. 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.
None
6. 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.
None
7. List all litigation or other legal proceedings (including arbitration proceedings), if any, in the last 1.0 years brought against
your firm, or any of the firm's past or present owners, principal shareholders or stockholders, officers, agents or
employees, that relate to or arise 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.
None
Proposal Forms COFMM/SVCS v.08.11.2D21
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RW
URCf1ASfN0ard
12007 Research Boulevard • Austin, Texas 78759-2439 • PH: 800-695-2919 • FAX: 800-211-5454 • buvboard.corn
REOUIRED FORMS CHECKLIST
(Please check (d) the following)
0 Reviewed/Comoleted: Proposer's Acceptance and Agreement
PROPOSAL FORMS PART 1: COMPLIANCE FORMS
0 Revlewed/ComDleted; Proposal Acknowledgements
0 Reviewed/Completed: Felony Conviction Disclosure
Reviewed/Completed: Resident/Nonresident Certification
Reviewed/Completed: Debarment Certification
xX Reviewed/COmDleted; Vendor Employment Certification
Fx I Reviewed/Completed: No Boycott Verification
[] Reviewed/Completed: No Excluded Nation or Foreign Terrorist Organization Certification
Reviewed/ComDleted: Historically Underutilized Business Certification
0 Reviewed/Completed: Acknowledgement of BuyBoard Technical Requirements
FI Reviewed/Completed: Construction -Related Goods and Services Affirmation
Reviewed/ComDleted: Deviation and Compliance
0 Revlewed/ComDleted: Vendor Consent for Name Brand Use
xx Reviewed/ComDleted; Confidential/Proprietary Information
F-1 Reviewed/ComDleted: EDGAR Vendor Certification
n Reviewed/ComDleted; Compliance Forms Signature Page
PROPOSAL FORMS PART 2: VENDOR INFORMATION FORMS
A Revlewed/ComDleted: Vendor Business Name
F. Reviewed/Commoleted: Vendor Contact Information (complete in electronic proposal submission system)
0 Reviewed/ComDleted: Federal and State/Purchasing Cooperative Experience
Fx] Rev! ewedlCompleted: Governmental References
P Reviewed/ComDleted: Company Profile
Reviewed/Completed: Texas Regional Service Designation (complete in eiectronieproposaisubmissionsysten))
C] Reviewed/ComDleted; State Service Designation (complete In electronicproposalsubmissionsystem)
P Reviewed/Completed: National Purchasing Cooperative Vendor Award Agreement (vendorsseming outside Texas only)
0 Reviewed/ComDleted: Local/Authorized Seller listings
R Reviewed/Completed: Manufacturer Dealer Designation
k] Reviewed/ComDleted: Proposal Invitation Questionnaire
n Reviewed/Completed: Vendor Request to Self -Report BuyBoard Purchases (optional)
Fy-,] Reviewed/ComDleted; Proposal Specifications Discount (%) off Catalog/Pricellst and/or other required pricing
information including Catalogs/Pricelists (or no bld response) must be submitted with the Proposal or the Proposal will not
be considered,
Proposal Forms COMM/SVCS v.08.11.2021
Page 39 of 71
PURCHASING COOPERATIVE
12007 Research Boulevard • Austin, Texas 78759-2439 , PH: 800-695-2919 , FAX. 800-211-5454 buvboard.com
PROPOSAL SPECIFICATION SUMMARY
The categories and items specified for this Proposal Invitation are summarized below. For full Proposal
Specifications, you must review and complete the Proposal Specification information in the electronic proposal
submission system in accordance with the Instructions to Proposers (or, if submitting a hard copy Proposal, timely
request and complete the Proposal Specification Form in accordance with the Instructions to Proposers).
PROPOSAL NOTE: Vendors shall submit catalog (s)/pri celist(s) with their Proposal response or the Proposal will not be
considered. Vendors shall submit catalog(s)/pricelist(s) with the Proposal in a readily available and readable electronic format,
with Excel or searchable PDF preferred. No pap-er catalogs or manufacturer/vendor websites will be accented.
Section I: Eauipment. Products. and Suaulies
1 . Discount (%) off catalog/pricelist for Water and Wastewater Pumps - Wholesale Product Line.
2. Discount (%) off catalog/pricelist for Water and Wastewater Pumps - Engineered Product Line (For this line -
item vendor shall propose base model engineered water pumps. Engineered product options, see line #3 below, will be
selected by the Cooperative member at the time of order).
3. Discount (%) off catalog/pricelist for Water and Wastewater Pumps - Optional Equipment and Parts for
Engineered Product Line (Options will be selected by the Cooperative member at the time of order. A COMPLETE
LIST OF ALL OPTIONAL EQUIPMENT AND PARTS MUST BE SUBMITTED WITH PROPOSAL FOR PROPOSAL TO BE
CONSIDERED.)
4. Discount (%) off catalog/pricelist for Water and Wastewater Pumps - Utility Services Sewer Lift Station.
S , Discount (%) off catalog/pricelist for Parts for Water and Wastewater Pumps and Motors.
6. Discount (%) off catalog/pricelist for Package Residential and Commercial Waste Grinder Station.
7. Discount (%) off catalog/pricelist for All Other Water and Wastewater Pumps and Motor Related Products.
Section II: Compliance Services - Water and Wastewater System Operators
8. Discount (%) off catalog/prlcelist for Compliance Services for Water and Wastewater System Operators -
(evaluation and testing for compliance of water and wastewater, development/review of emergency response plans,
training/continuing education for risk management plan compliance, development/review of client process plans for
regulatory compliance with the Environmental Protection Agency (EPA) or other regulatory agency audit requirements
and related services).
Section III: Installation and Repair Service
9. Hourly Labor Rate for Installation/ Repair Service of Water and Wastewater Pumps, Motors, and Related
Items -- Not to Exceed hourly labor rate for Installation/Repair Service of Equipment and Products.
Proposal Forms COMM/SVCS v.08A1.2021
Page 38 of 71
ard 0
OOOPERATIVE
672-22
A W Chesterton
Supplier Response
Event Information
Number: 672-22
Title: Water and Wastewater Pumps and Motors
Type: Request for Proposal
Issue Date: 11 /10/2021
Deadline: 1/20/2022 04:00 PM (CT)
Notes:
The Local Government Purchasing Cooperative (BuyBoard)
Proposal Invitation No. 672-22
Water and Wastewater Pumps and Motors
Proposal Due Date and Time: January 20, 2022, at 4:00 PM
Responding to this and future proposals online is easy with
our online submission system.
1. View and download the forms.
• DO NOl log in to view and download the documents.
• Visit vendor.buvboard.com and click on the "Current Proposal
Invitations" button
shown below to view and download the forms for this
proposal.
To submit completed proposal.
• Visit vendor.buvboard.com and click "Register/Login/Submit
Page 1 of 23 pages Vendor: A W Chesterton 672-22
Proposal" button shown
below to submit your proposal online.
• For additional assistance click this link I View our Proposal
Submission Instructions.
New Vendor? Visit vendor.buvboard.com and click
"Register/Login/Submit Proposal."
Click Rea_ ister now as a new supplier/vendor, so you don't miss future
proposal opportunities.
Any Addenda issued with this proposal will also be placed on the
website, and it will be the
vendor's responsibility to obtain the information.
Page 2 of 23 pages Vendor: A W Chesterton 672-22
A W Chesterton Information
Contact: Trent Elizondo
Address: 5808 Genoa - Red Bluff
Pasadena, TX 77505
Phone: (713) 920-5252
Email: trent.elizondo@chesterton.com
Web Address: www.chesterton.com
By submitting your response, you certify that you are authorized to represent and bind your company.
Kim Bauer kim.bauer@chesterton.com
Signature Email
Submitted at 112012022 2:29:22 PM
Requested Attachments
BuyBoard Proposal Invitation No. 672-22 Water and Wastewater BuyBoard proposal 672-22 final.pdf
Pumps and Motors
REQUIRED -In PDF format, upload all proposal invitation documents available for download at vendor.buyboard.com
including any additional pages, as necessary. (Please DO NOT password protect uploaded files.)
Catalog/Pricelist
2022 442 Pricing Buy Board Submittal.pdf
REQUIRED -In Excel or PDF format, upload catalog (s)/price Iist(s) in accordance with proposal invitation instructions.
Vendors shall submit catalog (s)/pricelist(s) with their Proposal response or Proposal will not be considered. No paper
catalogs or manufacturer/vendor websites will be accepted. File size must not exceed 100MB. (Please DO NOT
password protect uploaded files.)
Exceptions and/or Detailed Information Related to Discount % and/or Hourly Labor Rate Sheet.pdf
Labor Rate Proposed
In PDF format and if necessary, vendor shall attach detailed information regarding exceptions to pricing and/or
discount percentage and define the services that are proposed to be provided. NOTE: IF DETAILED INFORMATION IS
NOT SUBMITTED, PROPOSAL MAY NOT BE CONSIDERED. (Please DO NOT password protect uploaded files.)
Company Profile
history.doc
REQUIRED -Information on awarded Cooperative Contracts is available to Cooperative Members on the BuyBoard
website. If your company is awarded a Contract under this Proposal Invitation, please provide a brief company
description that you would like to have included with your company profile on the BuyBoard website. Submit your
company profile in a separate file, in Word format, with your Proposal. (Note: Vendor is solely responsible for any
content provided for inclusion on the BuyBoard website. The Cooperative reserves the right to exclude or remove any
content in its sole discretion, with or without prior notice, including but not limited to any content deemed by the
Cooperative to be inappropriate, irrelevant to the Contract, inaccurate, or misleading.)
IRS Form W-9 Request for Taxpayer Identification Number and Certification W9 2021.pdf
REQUIRED -In PDF format, upload W-9 form. (Please DO NOT password protect uploaded files.)
Response Attachments
MP 2022 GLOBAL USD_PRICE LIST.pdf
Chesterton Mechanical Packing Price List.
ARC 2022 GLOBAL USD_PRICE LIST.pdf
Chesterton ARC Industrial Coatings price list. Coatings are for the erosion and corrosion protection of pumps,
rebuilding of worn parts and improvement of the fluid efficiency properties of the equipment.
Page 3 of 23 pages Vendor: A W Chesterton 672-22
ENVIS 2022 ST_PRICELIST_2022_USD_C.pdf
Enviroseal, solids control stuffing box bushing price list.
Smart IIOT Products 2022 GLB USD_PRICE LIST.pdf
Chesterton Connect Price list. Bluetooth equipment monitoring device for vibration, surface temperature, process
pressure/temperature with cloud based data management platform. Designed to monitor pump & seal health.
Chesterton Terms and Conditions of Sale on Letterhead (2).pdf
Chesterton Terms and Conditions. Section 7 addresses Returns.
Bid Attributes
1 Federal Identification Number
Federal Identification Number
104-1173400
2 HUB/No Israel Boycott Certification/No Excluded Nation or Foreign Terrorist Certification
HUB/No Israel Boycott Certification/No Excluded Nation or Foreign Terrorist Certification
3 No Israel Boycott Certification
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 on the Compliance Forms Signature Page, to the extent applicable, 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.
Yes
4 No Excluded Nation or Foreign Terrorist Organization Certification
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 on the Compliance Forms Signature Page, 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.
Yes I
Page 4 of 23 pages Vendor: A W Chesterton 672-22
5 MWBE/HUB Status 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 BuyBoard website will indicate HUB certifications
for awarded Vendors that properly indicate and document their HUB certification on this form.
certify that my company has been certified as a MWBE/HUB in the following categories: (Please check all that
apply)
6 Minority Owned Business
Minority Owned Business
❑ Minority Owned Business (Yes)
7 Women Owned Business
Women Owned Business
❑ Women Owned Business (Yes)
8 Service -Disabled Veteran 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)
❑ Service -Disabled Veteran Owned Business (Yes)
9 Certification Number
Certification Number
No response
1 Name of Certifying Agency
U Certifying Agency
No response
1 Non-MWBE/HUB
1 My company has NOT been certified as a MWBE/HUB
❑ Non -HUB (Yes)
L12
Vendor General Contact Information
Proposal/Contract General Contact Information
1 Vendor Proposal/Contract Contact Name
3 Vendor Proposal/Contract Contact Name
Trent Elizondo
1 Vendor Proposal/Contract Contact E-mail Address
4 Vendor Proposal/Contract Contact E-mail Address
Trent.Elizondo@chesterton.com
1 Vendor Proposal/Contract Mailing Address
5 Vendor Proposal/Contract Mailing Address
15808 Genoa Red Bluff
Page 5 of 23 pages Vendor: A W Chesterton 672-22
1 Vendor Proposal/Contact Mailing Address - City
6 Vendor Proposal/Contact Mailing Address - City
Pasadena
1 Vendor Proposal/Contact Mailing Address - State
7 Vendor Proposal/Contact Mailing Address - State (Abbreviate State Name)
Texas
1 Vendor Proposal/Contact Mailing Address - Zip Code
8 Vendor Proposal/Contact Mailing Address - Zip Code
177507
1 Vendor Proposal/Contact Phone Number
9 Vendor Proposal/Contact Phone Number (xxx-xxx-=(c)
18177731187
2 Vendor Proposal/Contact Extension Number
U Vendor Proposal/Contact Extension Number
No response
2 Company Website
1 Company Website (www.xxxxx.com)
www.chesterton.com
2
2
Purchase Orders Contact Information
All Purchase Orders from Cooperative members will be available through the Internet. Vendors need Internet
access and at least one e-mail 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 below for receipt of Purchase Orders and provide the requested information:
• I will use the internet to receive Purchase Orders at the following address
Yes I
2 Purchase Order E-mail Address
3 Purchase Order E-mail Address
PasadenaOrders@chesterton.com
2 Purchase Order Contact Name
4 Purchase Order Contact Name
Jane Webb
2 Purchase Order Contact Phone Number
5 Purchase Order Contact Phone Number (xxx-xxx-)o=)
1713-920-5252
Page 6 of 23 pages Vendor: A W Chesterton 672-22
2 Purchase Order Contact Extension Number
6 Purchase Order Contact Extension Number
No response
2 Alternate Purchase Order E-mail Address
7 Alternate Purchase Order E-mail Address
trent.elizondo@chesterton.com
2 Alternate Purchase Order Contact Name
8 Alternate Purchase Order Contact Name
Trent Elizondo@chesterton.com
2 Alternate Purchase Order Contact Phone Number
9 Alternate Purchase Order Contact Phone Number (xxx-xxx-xxxx)
1 817-773-1187
3 Alternate Purchase Order Contact Extension Number
U Alternate Purchase Order Contact Extension Number
No response
3 Purchase Orders Contact Information
All Purchase Orders from Cooperative members will be available through the Internet. Vendors need Internet
access and at least one e-mail 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 below for receipt of Purchase Orders and provide the requested information:
• 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.
Yes I
3 Request for Quotes (5EceRFQ5E)
2 Cooperative members will send RFQs to you by e-mail
3 Request for Quote (RFQ) E-mail Address
3 Request for Quote (RFQ) E-mail Address
PasadenaOrders@chesterton.com
3 Request for Quote (RFQ) Contact Name
4 Request for Quote (RFQ) Contact Name
Jane Webb
Please provide e-mail addresses for the receipt of RFQs:
3 Request for Quote (RFQ) Contact Phone Number
5 Request for Quote (RFQ) Contact Phone Number (xxx-xxx-moo
1713-920-5252
Page 7 of 23 pages Vendor: A W Chesterton 672-22
3 Request for Quote (RFQ) Contact Extension Number
6 Request for Quote (RFQ) Contact Extension Number
No response
3 Alternate Request for Quote (RFQ) E-mail Address
7 Alternate Request for Quote (RFQ) E-mail Address
Trent.Elizondo@chesterton.com
3 Alternate Request for Quote (RFQ) Contact Name
8 Alternate Request for Quote (RFQ) Contact Name
Trent Elizondo
3 Alternate Request for Quote (RFQ) Contact Phone Number
9 Alternate Request for Quote (RFQ) Contact Phone Number (xxx-xxx-xxxx)
1 817-773-1187
4 Alternate Request for Quote (RFQ) Contact Extension Number
U Alternate Request for Quote (RFQ) Contact Extension Number
No response
4 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.
4 Invoices
2 Please choose only one (1) of the following options for receipt of invoices and provide the requested
information:
(a) Service fee invoices and related communications should be provided directly to my company at:
or
(b) In lieu of my company, I request and authorize all service fee invoices to be provided directly to the following
billing agent:
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.
Service fee invoices and notices direct to company
4 Invoice Company Name
3 Invoice Company Name
AW Chesterton Co.
4 Invoice Company Department Name
4 Invoice Company Department Name
AW Chesterton Co.
Page 8 of 23 pages Vendor: A W Chesterton 672-22
4 Invoice Contact Name
5 Invoice Contact Name
Jane Webb
4 Invoice Mailing Address
6 Invoice Mailing Address (P.O. Box or Street Address)
15808 Genoa Red Bluff
4 Invoice Mailing Address - City
7 Invoice Mailing Address - City
Pasadena
4 Invoice Mailing Address - State
8 Invoice Mailing Address - State (Abbreviate State Name)
Texas
4 Invoice Mailing Address - Zip Code
9 Invoice Mailing Address (Zip Code)
177507
5 Invoice Contact Phone Number
U Invoice Contact Phone Number (xxx-xxx-xxxx)
1713-920-5252
5 Invoice Contact Extension Number
Invoice Contact Extension Number
No response
5 Invoice Contact Fax Number
2 Invoice Contact Fax Number (xxx-xxx-xxxx)
No response
5 Invoice Contact E-mail Address
3 Invoice Contact E-mail
Jane.Webb@chesterton.com
5 Invoice Contact Alternate E-mail Address
4 Invoice Contact Alternate E-mail Address
Latoya.Salone@chesterton.com
5 Billing Agent Company Name
5 Billing Agent Company Name
No response
5 Billing Agent Department Name
6 Billing Agent Department Name
No response
Page 9 of 23 pages Vendor: A W Chesterton 672-22
5 Billing Agent Contact Name
7 Billing Agent Contact Name
No response
5 Billing Agent Mailing Address
8 Billing Agent Mailing Address (P.O. Box or Street Address)
No response
5 Billing Agent Mailing Address - City
9 Billing Agent Mailing Address - City
No response
6 Billing Agent Mailing Address - State
U Billing Agent Mailing Address - State (Abbreviate State Name)
No response
6 Billing Agent Mailing Address - Zip Code
Billing Agent Mailing Address - Zip Code
No response
6 Billing Agent Contact Phone Number
2 Billing Agent Contact Phone Number (xxx-xxx-xxxx)
No response
6 Billing Agent Contact Extension Number
3 Billing Agent Contact Extension Number
No response
6 Billing Agent Fax Number
4 Billing Agent Fax Number
No response
6 Billing Agent Contact E-mail Address
5 Billing Agent Contact E-mail Address
No response
6 Billing Agent Alternative E-mail Address
6 Billing Agent Alternative E-mail Address
No response
6 Shipping Via
7 Common Carrier, Company Truck, Prepaid and Add to Invoice, or Other
Prepaid and Add to Invoice I
Page 10 of 23 pages Vendor: A W Chesterton 672-22
6 Payment Terms
8 Note: Vendor payment terms must comply with the BuyBoard General Terms and Conditions and the Texas Prompt
Payment Act (Texas Government Code Ch. 2251).
I Payment terms are Net 30 days
6 Vendor's Internal/Assigned Reference/Quote Number
9 Vendor's Internal/Assigned Reference/Quote Number
I No response
7 State or Attach Return Policy
U Note: Only return requirements and processes will be deemed part of Vendor's return policy. Any unrelated contract
terms, terms of sale, or other information not specifically related to return requirements and processes included in
Vendor's return policy shall not apply to any awarded Contract unless specifically included as a deviation in the
Deviation and Compliance Form and accepted by the Cooperative.
I Terms and conditions are attached in documents. Section 7 specifically addresses returns.
7 Electronic Payments
Are electronic payments acceptable to your company?
IYes I
7 Credit Card Payments
2 Are credit card payments acceptable to your company?
IYes
7 Texas Regional Service Designation
3 Texas Regional Service Designation - Refer to Form in Proposal Invitation
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. 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 (i.e., if you will service only states other than Texas), you must
so indicate on this form.
7 Company Name
4 Company Name
I AW Chesterton Co.
7 Texas Regional Service Designation
5 Select only one of the following options. If you select "I will NOT serve all Regions of Texas", you must then
check the individual Regions you wish to serve.
IAII Regions
7 Region 1
6 Region 1 - Edinburg
❑ Region 1 (1)
Page 11 of 23 pages Vendor: A W Chesterton 672-22
7
Region 2
7
Region 2 - Corpus Christi
❑ Region 2 (2)
7
Region 3
8
Region 3 - Victoria
❑ Region 3 (3)
7
Region 4
9
Region 4 - Houston
❑ Region 4 (4)
8
Region 5
0
Region 5 - Beaumont
❑ Region 5 (5)
8
Region 6
1
Region 6 - Huntsville
❑ Region 6 (6)
8
Region 7
2
Region 7 - Kilgore
❑ Region 7 (7)
8
Region 8
3
Region 8 - Mount Pleasant
❑ Region 8 (8)
8
Region 9
4
Region 9 - Wichita Falls
❑ Region 9 (9)
8
Region 10
5
Region 10 - Richardson
❑ Region 10 (10)
8
Region 11
6
Region 11 - Fort Worth
❑ Region 11 (11)
8 Region 12
7 Region 12 - Waco
❑ Region 12 (12)
8 Region 13
8 Region 13 - Austin
❑ Region 13 (13)
Page 12 of 23 pages Vendor: A W Chesterton 672-22
8
Region 14
9
Region 14 - Abilene
❑ Region 14 (14)
9
Region 15
0
Region 15 - San Angelo
❑ Region 15 (15)
9
Region 16
Region 16 - Amarillo
❑ Region 16 (16)
9
Region 17
2
Region 17 - Lubbock
❑ Region 17 (17)
9
Region 18
3
Region 18 - Midland
❑ Region 18 (18)
9
Region 19
4
Region 19 - El Paso
❑ Region 19 (19)
9
Region 20
5
Region 20 - San Antonio
❑ Region 20 (20)
9
6
State Service Designation
State Service Designation - Refer to Form in Proposal Invitation.
As set forth in the Proposal Invitation, it is the Cooperative's intent that other governmental entities in the United
States have the opportunity to purchase goods or services awarded under the Contract, subject to applicable state
law, through a piggy -back award or similar agreement through the National Purchasing Cooperative BuyBoard. If
you plan to service the entire United States or only specific states, you must complete this form accordingly. (Note:
If you plan to service Texas Cooperative members, be sure that you complete the Texas Regional Service
Designation form.) In addition to this form, to be considered for a piggy -back award by the National
Purchasing Cooperative, you must have an authorized representative sign the National Purchasing
Cooperative Vendor Award Agreement that follows this 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. 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.
9 Company Name
7 Company Name
JAW Chesterton Co.
Page 13 of 23 pages Vendor: A W Chesterton 672-22
9 State Service Designation
8 Select only one of the following options.
the individual States you wish to serve.
I will not serve all states in the United States
9 Alabama
9 Alabama
❑ Alabama (AL)
1 Alaska
0 0 Alaska
❑ Alaska (AK)
1
Arizona
Arizona
❑ Arizona (AZ)
1
Arkansas
0
Arkansas
❑ Arkansas (AR)
If you select "I will NOT serve all States", you must then check
1 California
0 California (Public Contract Code 20118 & 20652)
3
❑ California (CA)
1 Colorado
0 Colorado
4
❑ Colorado (CO)
1 Connecticut
0 Connecticut
❑ Connecticut (CT)
1 Delaware
0 Delaware
❑ Delaware (DE)
1 District of Columbia
0 District of Columbia
7
❑ District of Columbia (DC)
1
Florida
0
8
Florida
❑ Florida (FL)
1
Georgia
9
Georgia
❑ Georgia (GA)
Page 14 of 23 pages Vendor: A W Chesterton 672-22
1 Hawaii
0 Hawaii
❑ Hawaii (HI)
1 Idaho
1 Idaho
1
❑ Idaho (ID)
1 Illinois
1 Illinois
2
❑ Illinois (IL)
1 Indiana
3 Indiana
❑ Indiana (IN)
1 Iowa
4 Iowa
❑ Iowa (IA)
1 Kansas
1 Kansas
❑ Kansas (KS)
1 Kentucky
1 Kentucky
6
❑ Kentucky (KY)
1 Louisiana
7 Louisiana
❑ Louisiana (LA)
1 Maine
8 Maine
❑ Maine (ME)
1 Maryland
1
9 Maryland
❑ Maryland (ME)
1 Massachusetts
2 Massachusetts
0
❑ Massachusetts (MA)
1 Michigan
2 Michigan
1
❑ Michigan (MI)
Page 15 of 23 pages Vendor: A W Chesterton 672-22
1 Minnesota
2 Minnesota
❑ Minnesota (MN)
1 Mississippi
2 3 Mississippi
❑ Mississippi (MS)
1 Missouri
4 Missouri
❑ Missouri (MO)
1 Montana
5 Montana
❑ Montana (MT)
1 Nebraska
6 Nebraska
❑ Nebraska (NE)
1 Nevada
7 Nevada
❑ Nevada (NV)
1 New Hampshire
8 New Hampshire
❑ New Hampshire (NH)
1 New Jersey
9 New Jersey
❑ New Jersey (NJ)
1 New Mexico
UNew Mexico
❑ New Mexico (NM)
1 New York
New York
❑ New York (NY)
1 North Carolina
2 North Carolina
❑ North Carolina (NC)
1 North Dakota
3 North Dakota
❑ North Dakota (ND)
Page 16 of 23 pages Vendor: A W Chesterton 672-22
1 Ohio
4 Ohio
❑ Ohio (OH)
1 Oklahoma
3 Oklahoma
❑ Oklahoma (OK)
1 Oregon
3 Oregon
❑ Oregon (OR)
1 Pennsylvania
3 Pennsylvania
❑ Pennsylvania (PA)
1 Rhode Island
3 Rhode Island
❑ Rhode Island (RI)
1 South Carolina
3 South Carolina
❑ South Carolina (SC)
1 South Dakota
4 South Dakota
0
❑ South Dakota (SD)
1 Tennessee
Tennessee
❑ Tennessee (TN)
1 Texas
4 Texas
❑ Texas (TX)
1 Utah
4 Utah
3
❑ Utah (UT)
1 Vermont
4 Vermont
❑ Vermont (VT)
1 Virginia
4 Virginia
❑ Virginia (VA)
Page 17 of 23 pages Vendor: A W Chesterton 672-22
1 Washington
44 Washington
❑ Washington (WA)
1 West Virginia
4 West Virginia
7
❑ West Virginia (WV)
1 Wisconsin
4 Wisconsin
❑ Wisconsin (WI)
4 Wyoming
9 Wyoming
❑ Wyoming (WY)
Bid Lines
1 Section I: Eauiament. Products. and Suaalies - Discount (%) off catalog/pricelist for Water and Wastewater
Pumps - Wholesale Product Line. Catalog/Pricelist MUST be included or proposal will not be considered.
No Bid
Item Notes: Vendors proposing multiple manufacturer product lines and/or catalog/pricelist per line item must submit
the information as follows or proposal may not be considered:
• Select "Add Alternate" for each additional manufacturer product line and/or catalog/pricelist
proposed
• Vendor's must list one specific percentage discount for each manufacturer and/or
catalog/pricelist listed
Item Attributes
1. State Name of Catalog/Pricelist Proposed with Discount Percentage
NOTE: Do not include SKU, Reference Numbers, Websites, and/or "See Attached/Enclosed".
No response
Page 18 of 23 pages Vendor: A W Chesterton 672-22
2 Section I: Eauipment. Products. and Suaalies - Discount (%) off catalog/pricelist for Water and Wastewater
Pumps - Engineered Product Line (For this line -item vendor shall propose base model engineered water
pumps. Engineered product options, see line #3 below, will be selected by the Cooperative member at the time
of order). Catalog/Pricelist MUST be included or proposal will not be considered.
1►Tf0T jA
Item Notes: Vendors proposing multiple manufacturer product lines and/or catalog/pricelist per line item must submit
the information as follows or proposal may not be considered:
• Select "Add Alternate" for each additional manufacturer product line and/or catalog/pricelist
proposed
• Vendor's must list one specific percentage discount for each manufacturer and/or
catalog/pricelist listed
Item Attributes
1. State Name of Catalog/Pricelist Proposed with Discount Percentage
NOTE: Do not include SKU, Reference Numbers, Websites, and/or "See Attached/Enclosed".
No response
3 Section I: Eauir)ment. Products. and Sunnlies - Discount (%) off catalog/pricelist for Water and Wastewater
Pumps - Optional Equipment and Parts for Engineered Product Line (Options will be selected by the
Cooperative member at the time of order. A COMPLETE LIST OF ALL OPTIONAL EQUIPMENT AND PARTS
MUST BE SUBMITTED WITH PROPOSAL FOR PROPOSAL TO BE CONSIDERED.) Catalog/Pricelist MUST
be included or proposal will not be considered.
No Bid
Item Notes: Vendors proposing multiple manufacturer product lines and/or catalog/pricelist per line item must submit
the information as follows or proposal may not be considered:
• Select "Add Alternate" for each additional manufacturer product line and/or catalog/price list
proposed
• Vendor's must list one specific percentage discount for each manufacturer and/or
catalog/pricelist listed
Item Attributes
1. State Name of Catalog/Pricelist Proposed with Discount Percentage
NOTE: Do not include SKU, Reference Numbers, Websites, and/or "See Attached/Enclosed".
No response
Page 19 of 23 pages Vendor: A W Chesterton 672-22
4
5
Section I: Eauir)ment. Products. and Supplies, - Discount (%) off catalog/pricelist for Water and Wastewater
Pumps - Utility Services Sewer Lift Station. Catalog/Pricelist MUST be included or proposal will not be
considered.
No Bid
Item Notes: Vendors proposing multiple manufacturer product lines and/or catalog/pricelist per line item must submit
the information as follows or proposal may not be considered:
• Select "Add Alternate" for each additional manufacturer product line and/or catalog/pricelist
proposed
• Vendor's must list one specific percentage discount for each manufacturer and/or
catalog/pricelist listed
Item Attributes
1. State Name of Catalog/Pricelist Proposed with Discount Percentage
NOTE: Do not include SKU, Reference Numbers, Websites, and/or "See Attached/Enclosed".
No response
Section I: Eauioment. Products. and Supplies. - Discount (%) off catalog/pricelist for Parts for Water and
Wastewater Pumps and Motors. Catalog/Pricelist MUST be included or proposal will not be considered.
No Bid
Item Notes: Vendors proposing multiple manufacturer product lines and/or catalog/pricelist per line item must submit
the information as follows or proposal may not be considered:
• Select "Add Alternate" for each additional manufacturer product line and/or catalog/pricelist
proposed
• Vendor's must list one specific percentage discount for each manufacturer and/or
catalog/pricelist listed
Item Attributes
1. State Name of Catalog/Pricelist Proposed with Discount Percentage
NOTE: Do not include SKU, Reference Numbers, Websites, and/or "See Attached/Enclosed".
No response
Page 20 of 23 pages
Vendor: A W Chesterton
672-22
6
7
Section I: Eauipment. Products. and Suaalies - Discount (%) off catalog/pricelist for Package Residential
and Commercial Waste Grinder Station. Catalog/Pricelist MUST be included or proposal will not be
considered.
No Bid
Item Notes: Vendors proposing multiple manufacturer product lines and/or catalog/pricelist per line item must submit
the information as follows or proposal may not be considered:
• Select "Add Alternate" for each additional manufacturer product line and/or catalog/pricelist
proposed
• Vendor's must list one specific percentage discount for each manufacturer and/or
catalog/pricelist listed
Item Attributes
1. State Name of Catalog/Pricelist Proposed with Discount Percentage
NOTE: Do not include SKU, Reference Numbers, Websites, and/or "See Attached/Enclosed".
No response
Section I: Eauipment. Products. and Sunalies - Discount (%) off catalog/pricelist for All Other Water and
Wastewater Pumps and Motor Related Products. Catalog/Pricelist MUST be included or proposal will not be
considered.
Total: 1 15% 1
Item Notes: Vendors proposing multiple manufacturer product lines and/or catalog/pricelist per line item must submit
the information as follows or proposal may not be considered:
• Select "Add Alternate" for each additional manufacturer product line and/or catalog/pricelist
proposed
• Vendor's must list one specific percentage discount for each manufacturer and/or
catalog/pricelist listed
Item Attributes
1. State Name of Catalog/Pricelist Proposed with Discount Percentage
NOTE: Do not include SKU, Reference Numbers, Websites, and/or "See Attached/Enclosed".
Mechanical Seals for Pumps
Alternate 1
Section I: Eauir)ment. Products. and Supplies - Discount (%) off cataloa/Dricelist for All Other Water and
Wastewater Pumas and Motor Related Products. Cataloa/Pricelist MUST be included or proposal will not be
considered.
Total: 1 15% 1
Page 21 of 23 pages Vendor: A W Chesterton 672-22
Item Attributes
1. State Name of Catalog/Pricelist Proposed with Discount Percentage
NO E: Do not include SKU, Reference Numbers, Websites, and/or "See Attached/Enclosed". T
Mechanical Packing for Pumps
Alternate 2
Section I: Eauiament. Products. and SuaDlies - Discount (%) off cataloa/Dricelist for All Other Water and
Wastewater Pumas and Motor Related Products. Cataloa_/Pricelist MUST be included or DrODosal will not be
considered.
Total: 1 20% 1
Item Attributes
1. State Name of Catalog/Pricelist Proposed with Discount Percentage
NO E: Do not include SKU, Reference Numbers, Websites, and/or "See Attached/Enclosed". T
ARC Epoxy Coatings for Pumps
Alternate 3
Section I: Eauiament. Products. and SuaDlies - Discount (%) off cataloa/Dricelist for All Other Water and
Wastewater Pumas and Motor Related Products. Cataloa_/Pricelist MUST be included or Dr000sal will not be
considered.
Total: 1 5% 1
Item Attributes
1. State Name of Catalog/Pricelist Proposed with Discount Percentage
NO E: Do not include SKU, Reference Numbers, Websites, and/or "See Attached/Enclosed". T
Chesterton Connect
Alternate 4
Section I: Eauiament. Products. and SUDDlies - Discount (%) off cataloa/Dricelist for All Other Water and
Wastewater Pumas and Motor Related Products. Cataloa_/Pricelist MUST be included or Dr000sal will not be
considered.
Total: 1 5% 1
Item Attributes
1. State Name of Catalog/Pricelist Proposed with Discount Percentage
NO E: Do not include SKU, Reference Numbers, Websites, and/or "See Attached/Enclosed". T
Enviroseal Spiraltrac Bushing
Page 22 of 23 pages Vendor: A W Chesterton 672-22
8 Section II: Compliance Services - Water and Wastewater Svstem Operators - Discount (%) off
catalog/pricelist for Compliance Services for Water and Wastewater System Operators - (evaluation and
testing for compliance of water and wastewater, development/review of emergency response plans,
training/continuing education for risk management plan compliance, development/review of client process plans
for regulatory compliance with the Environmental Protection Agency (EPA) or other regulatory agency audit
requirements and related services). Catalog/Pricelist MUST be included or proposal will not be considered.
No Bid
Item Notes: Vendors proposing multiple manufacturer product lines and/or catalog/pricelist per line item must submit
the information as follows or proposal may not be considered:
• Select "Add Alternate" for each additional manufacturer product line and/or catalog/pricelist
proposed
• Vendor's must list one specific percentage discount for each manufacturer and/or
catalog/pricelist listed
Item Attributes
1. State Name of Catalog/Pricelist Proposed with Discount Percentage
NOTE: Do not include SKU, Reference Numbers, Websites, and/or "See Attached/Enclosed".
No response
9 Section II: Installation and Repair Service - Hourly Labor Rate for Installation/Repair Service of Water
and Wastewater Pumps, Motors, and Related Items -- Not to Exceed hourly labor rate for Installation/Repair
Service of Equipment and Products.
Quantity: 1 UOM: Hourly Labor Rate Price: 1 $150.00 1 Total: 1 $150.00 1
Response Total: $150.00
Page 23 of 23 pages Vendor: A W Chesterton 672-22
EXHIBIT C
CONFLICT OF INTEREST QUESTIONNAIRE FORM CIO
For vendor doing business with local governmental entity
This questionnaire reflects changes made io the law by H.B. 23. 941h Leg., Regular Session. OFFICE IGEONLY
This questionnaire is being liled in accordanra with Ghapta�r 176. Laval Government Code, by a vendor who DaW peceiwed
has a business relationship as defined by Section 176-0010-a7 with a local gouernmen-al enlirg and the
vendor meats requirements under Section 176.006(a)-
fay law this questlonnaire must be liled with the records adminhaalor of the local gouen-rental entity not laser
than the 7th business day after the dale the vendor bommas arras of facts tha-, require the am-.ement io tie
filed. Sap Section 176-ao6(a-1), LacaJ Gcvemmoni Coda.
A vendor commits an olfanse if the vendor knowingly violates Section 176.046, Local Givemment Code- An
coarse under this section is a misdemeanor.
-11 Name of vendor who has a business relationship with local governmental entity.
J
Check ift is box if you arm tilt ng an ups is a previously fi Ind q uesfiannaire. (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 arare that the originally filed questionnaire was incomplete OF inaccurate.)
J Name of local government officerabout whom the information is being disclosed,.
Name of Off cer
J describe each employment or other business relationship with the local government officer, or a family member of the
officer, as described by Section 176.002(a)(2)(A). Also describe any family relationship with the local governrnentoff icer.
Complete subparts A and B for each employment or business miationship described. Attach additional pages to this Form
CIO as necessary.
A- Is the local government officer or a family member of the offioer receiving or likely to rOcaiwe taxable income,
other than irucstment income. from the vendor?
rlYes M N o
13- Is the vendor receiwing or likely to mcaivetaxable income, other than iriwestment income, from or at the direction
of the Iacal government officer OF a family rrembw of the officer AND the taxable income is not received tram the
local governmental entity?
riYes F1hf4
f?escribeeach 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 inlerest of one percent or more.
13 Chock this box if the vendor has given tti0local govern mart officer or a fern fly member of the officer one or more gifts
as described in Section 176.00%&)(2)(B), excluding gifts described in Section 176-003(a.-1 ).
F'"G2/�� Mar 28 2024
Benjami ittreich (Mar 28, 202411:40 EDT) ,
Sgnature of vendor doing business with the governmental entity V.
Form provided by Texas Ethics Commission wrm. athi cs.stata.lz. u s Re Ased 11V2021