Notice of Issuance by X69r57T3

VIEWS: 6 PAGES: 13

									                                                      APPENDIX “A”
                                                   RFS RESPONSE FORM
                                                     RFS NO. PB 12-13

1) For the right and privilege of operating and managing the eight (8) required pay telephones at the
   Airports, respondent hereby proposes to pay the County the following Annual Concession Fee:

                   Annual Concession Fee
           (may NOT be less than $1,000.00 per Contract Year)                  $ ________________

2) For each additional pay telephone to be installed at the Airports at respondent’s request/option,
   respondent hereby proposes to pay the County the following annual concession fee for each pay
   telephone:

                  Optional Telephone Fee
          (dollar amount per pay telephone per Contract Year)                $ ________________

3) For each additional pay telephone requested to be installed at the Airports by the County,
   respondent hereby proposes to complete the installation and connection of the pay telephone
   (including providing the necessary housing and fixture, if needed) for an amount not-to-exceed the
   following:

                           Airport Location                                           Installation Fee
                                                                           (dollar amount per pay telephone by location)

       Palm Beach International Airport (PBI)                                     $ ________________
      Palm Beach County Park Airport (LNA)                                        $ ________________
      Palm Beach County Glades Airport (PHK)                                      $ ________________
      North County General Aviation Airport (F45)                                 $ ________________

4) For the operation and maintenance of each additional pay telephone requested by the County,
   respondent proposes the County pay the following annual charge:

                  Additional Telephone Charge
           (dollar amount per additional telephone per Contract Year)            $ ________________

5) The following is a summary of respondent’s proposed rates and charges. Respondent
   acknowledges that any increase to rates and charges will need the written approval of the
   Department, and that no charge may be imposed in excess of any maximum charge set by any
   regulatory agency having jurisdiction.

                         Call Type                                                 Charge
      Directory Assistance & 411 Charge                                     $_____________ per call
      Local Direct Dial Coin Call with No Time Limit                        $_____________ per call
      Operator Assistance Surcharge                                         $___________________
      Surcharge for Payment by Credit Card                                  $___________________



                                                             Page 1 of 3
                                          APPENDIX “A”
                                       RFS RESPONSE FORM
                                         RFS NO. PB 12-13


6) The following is a summary of respondent’s sample charges for telephone calls (assume all
   sample telephone calls originate from a pay Telephone at PBIA, are four (4) minutes in duration
   and occur on a weekday, at 12:00 noon, local time):

   TO                            RATE TYPE                       CHARGES

   Local West Palm Beach, FL credit card; no operator

   Boca Raton, FL                direct dial; coin

   Port St. Lucie, FL            operator assisted

   Miami, FL                     direct dial; coin

   Boston, MA                    credit card; no operator

   New York, NY                  operator assisted

   San Francisco, CA             credit card; operator assist.

   Quebec, Canada                credit card; operator assist.

   Paris, France                 credit card; operator assist.

The undersigned certifies by signature below the following:

a.    He/she has legally made this offer in accordance with all requirements of this RFS and shall, if
successful respondent, execute a contract with Palm Beach County.

b.      This Submittal is submitted without prior understanding, agreement or connection with any
corporation, firm, or person submitting a Submittal for the same materials, services, and supplies as
is, in all respects, fair and without collusion or fraud.

c.    This Submittal is current, accurate, complete, and is presented to the County for the
performance of this contract in accordance with all the requirements as stated in this RFS.

d.      The financial stability to fully perform the terms and conditions as specified herein. The County
reserves the right to request financial information from the respondent at any time during the
solicitation process and in any form deemed necessary by the County.

e.    Respondent understands that County will only negotiate those exceptions to the Concession
Agreement that are specifically identified in accordance with Section 2.14 of the RFS and that the
County has no obligation whatsoever to accept any proposed exceptions.
                                              Page 2 of 3
                                        APPENDIX “A”
                                     RFS RESPONSE FORM
                                       RFS NO. PB 12-13



f.    Respondent understands that respondent may not propose any exceptions to the minimum
RFS requirements (see Section 3) and failure to satisfy the minimum requirements will result in the
submittal being deemed non-responsive.

IMPORTANT:

FAILURE TO SUBMIT THESE PAGES WILL BE CAUSE FOR IMMEDIATE REJECTION OF THE
ENTIRE SUBMITTAL RESPONSE.

ENTITY/COMPANY:

NAME (PRINT):

TITLE:

ADDRESS:

TELEPHONE NO.:

E-MAIL:


SIGNATURE:



Please affix corporate seal or have submittal notarized.



(Corporate seal)




OR:



Notary-Full Name                              (Notary Expiration & Seal)

Date:



                                           Page 3 of 3
                                    APPENDIX “B”
                                BUSINESS INFORMATION
                                   RFS NO. PB 12-13


Full Legal Name of Entity:
                                 (Exactly as it is to appear on the Contract/Concession Agreement)


Entity Address:



Telephone Number: (        )                     Fax Number: (    )
Form of Entity (check one and complete the appropriate entity statement attached
hereto)
[ ] Corporation (Complete forms page(s)     )
[ ] Limited Liability Company (Complete forms page(s)   )
[ ] Partnership, General (Complete forms page(s)      )
[ ] Partnership, Limited (Complete forms page(s)    )
[ ] Joint Venture (Complete forms page(s)     )
[ ] Sole Proprietorship
Federal I.D. Number:

(1) If Respondent is a subsidiary, state name of parent company.

Caution: All information provided herein must be as to Respondent (subsidiary) and not
as to parent company.

(2) If a corporation is a partner of a proposing partnership or a member of a proposing
joint venture, the corporation statement, attached hereto, must be completed in addition
to the appropriate Respondent’s business entity statement.

Is Entity registered to do business in the State of Florida? Yes [ ]                         No [ ]

If yes to the above, as of what date?

If not presently registered with the Division of Corporations to do business in the State
of Florida as either a Florida or foreign corporation, Respondent acknowledges, by
signing below, that if it is the Awardee it will register with the State of Florida prior to the
effective date of the contract with Palm Beach County.

SIGNATURE: _______________________

NAME (PRINT): ____________________

TITLE: ____________________________

COMPANY: ________________________
                             CORPORATION STATEMENT



If a Corporation, answer the following:

1.    When incorporated?

2.    Where incorporated?

3.    The Corporation is held:

           [ ] Publicly          [ ] Privately

4.    Has the Corporation previously offered                 pay   Telephone    services
      (as stated in the RFS) in the state of Florida?

           [ ] yes               [ ] no

      If yes, indicate Date:                     Location:

5.    Furnish the name, title and address of each director, officer, principal managers,
      and how long they have been employed.

6.    Attach a copy of the Corporate Certificate from the Secretary of State.

7.    Attach Credit references.
                         LIMITED LIABILITY COMPANY STATEMENT


If a Limited Liability Company (LLC), answer the following:

1.    Date of organization?

2.    Place of organization?

3.    The LLC is held:

           [ ] Publicly          [ ] Privately

4.    Indicate:    [ ] Member-Managed        or         [ ] Manager-Managed

5.    Is the LLC operating agreement recorded?          [ ] yes    [ ] no

      If yes, indicate
                         Date        Book               Page        Location

6.    Has the LLC previously offered pay Telephone services (as stated in the RFS) in
      the state of Florida?

           [ ] yes               [ ] no

      If yes, indicate Date:                      Location:

7.    Furnish the name, title, and address of each Member, Manager, and Managing
      Member and how long each has been employed.

8.    Attach a copy of the LLC Certificate from the Secretary of State.

9.    Attach one (1) copy of the LLC Operating Agreement.

10.   Attach Credit references.
                               PARTNERSHIP STATEMENT
                                  (General or Limited)

If a General or Limited Partnership, answer the following:

1.    Date of organization?

2.    Place of organization?

3.    Indicate:    [ ] General Partnership   or       [ ] Limited Partnership

4.    Is the Partnership agreement recorded?          [ ] yes      [ ] no

      If yes, indicate
                          Date           Book           Page                Location

5.    Has Partnership or any partner previously offered pay Telephone services (as
      stated in the RFS) in the state of Florida?

              [ ] yes       [ ] no

      If yes, indicate Date:                      Location:

6.    Furnish the name, title and address of each director, officer, principal
      manager(s), general or limited partner, and how long each has been employed.

7.    Attach one copy of the Partnership Agreement.

8.    Attach Credit references.
                                 JOINT VENTURE STATEMENT


If a Joint Venture, answer the following:

1.     Date of organization?

2.     Place of organization?

3.     Is the Joint Venture agreement recorded? [ ] yes      [ ] no

       If yes, indicate
                          Date            Book     Page          Location

4.     Has Joint Venture previously offered pay Telephone services (as stated in the
       RFS) in the state of Florida?

               [ ] yes           [ ] no

       If yes, indicate Date:                    Location:

5.     Furnish the name, title and address of each director, officer, principal
       manager(s), general or limited partner of Joint Venture and how long they have
       been employed.

6.     Attach one copy of the Joint Venture Agreement.

7.     Attach Credit references.
                                                       APPENDIX “C”

                                    DRUG-FREE WORKPLACE CERTIFICATION
                                             RFS NO. PB 12-13

IDENTICAL TIE SUBMITTALS - In accordance with Section 287.087, F.S., a preference will be given to vendors submitting with
their submittals the following certification that they have implemented a drug-free workplace program which meets the
requirements of Section 287.087; provided, however, that any preference given pursuant to Section 287.087, shall be made in
conformity with the requirements of the Palm Beach County Code, Chapter 2, Article III, Sections 2-80.21 through 2-80.34. In
the event tie submittals are received from vendors who have not submitted with their submittals a completed Drug-Free
Workplace Certification form, the award will be made in accordance with Palm Beach County's purchasing procedures
pertaining to tie submittals.

This Drug-Free Workplace Certification form must be executed and returned with the attached submittal, and received on or
before time of submittal opening to be considered. The failure to execute and/or return this certification shall not cause any
submittal to be deemed non-responsive.

Whenever two (2) or more submittals which are equal with respect to price, quality, and service are received by Palm Beach
County for the procurement of commodities or contractual services, a submittal received from a business that certifies that it has
implemented a drug-free workplace program shall be given preference in the award process. In order to have a drug-free
workplace program, a business shall:

(1)     Publish a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a
        controlled substance is prohibited in the workplace and specifying the actions that will be taken against employees for
        violations of such prohibition.

(2)     Inform employees about the dangers of drug abuse in the workplace, the business's policy of maintaining a drug-free
        workplace, any available drug counseling, rehabilitation, and employee assistance programs, and the penalties that
        may be imposed upon employees for drug abuse violations.

(3)     Give each employee engaged in providing the commodities or contractual services that are under bid a copy of the
        statement specified in number (1).

(4)     In the statement specified in number (1), notify the employees that, as a condition of working on the commodities or
        contractual services that are under bid, the employee will abide by the terms of the statement and will notify the
        employer of any conviction of, or plea of guilty or nolo contendere to, any violation of Chapter 893, Florida Statutes, or
        of any controlled substance law of the United States or any state, for a violation occurring in the workplace no later than
        five (5) days after such conviction.

(5)     Impose a sanction on, or require the satisfactory participation in a drug abuse assistance or rehabilitation program if
        such is available in the employee's community, by any employee who is so convicted.

(6)     Make a good faith effort to continue to maintain a drug-free workplace through implementation Section 287.087, Florida
        Statutes.

THIS CERTIFICATION is submitted by __________________________________________________________ the
                                        (Individual’s Name)

                                                               of _____________________________________________
       (Title/Position with Company/Vendor)                            (Name of Company/Vendor)

who does hereby certify that said Company/Vendor has implemented a drug-free workplace program which meets
the requirements of Section 287.087, Florida Statutes, which are identified in numbers (1) through (6) above.

                                                            _________________________               _____________________
                                                            Signature                               Date
          APPENDIX D
          SCHEDULE 1
LIST OF PROPOSED ACDBE FIRMS
        RFS No. PB 12-13
                                                                                           SCHEDULE 1
                                                                                 LIST OF PROPOSED ACDBE FIRMS
                                                                                       RFS #PB 12-13
                                                                           PAY TELEPHONE CONCESSION AGREEMENT
                                                                           THE PALM BEACH INTERNATIONAL AIRPORT
Name of Respondent: _____________________________________________                                       Phone No.: __________________________ Fax No: ___________________

Contact Person: __________________________________________________                                      E-mail Address: ________________________________________________

Address: ________________________________________________________                                       Respondent’s Estimated Annual Gross Revenues: $_________________
                                                                                                                                                                (1)
                                                                                                 Percentage of ACDBE Participation by Race/Gender
    Name, Address &                  Description of                  Classification
      Phone No. of                   Type of Work                  (Check applicable box)     Black          Hispanic            Women                     Other
                 (2)
     ACDBE Firm                                                                                                                                        (Please Specify)
                                                              □ Prime Contractor
                                                              □ Subcontractor
                                                              □ Supplier
                                                                                            ________%      _________%          ________%              __________%
                                                              □ Manufacturer
                                                              □ Joint Venture
                                                              □ Prime Contractor
                                                              □ Subcontractor
                                                                                            ________%      _________%          ________%              __________%
                                                              □ Supplier
                                                              □ Manufacturer
                                                              □ Joint Venture
                                                              □ Prime Contractor
                                                              □ Subcontractor
                                                              □ Supplier
                                                                                            ________%      _________%          ________%              __________%
                                                              □ Manufacturer
                                                              □ Joint Venture

  Total Percentage of                                                                       ________%      +________%         +________%             +__________%               =__________%
                     (3)
 ACDBE Participation

Notes:
1. The percentages listed on this form for each ACDBE Firm must be supported by the percentage included on Schedule 2, “Letter of Intent to Perform as an Airports Concession Disadvantaged Business
    Enterprise”.
2. It is the obligation of proposer to confirm that firms identified on this form must be certified as an ACDBE by the State of Florida’s Unified Certification Program.
3. ACDBE participation is measured as a percentage of annual gross revenues.

By signing this form the undersigned Respondent is committing to utilize the above-referenced ACDBE Firms pursuant to the Concession Agreement. Substitutions of
ACDBE Firms during the term of the Concession Agreement shall be subject to prior written approval of the Department of Airports.

By: _______________________________________________
     Signature

__________________________________________________                                                                                                    *Additional sheets may be used if necessary.
Print Name/Title of Person Executing on Behalf of the Respondent

Date:______________________________________________                                                                                                   ACDBE      Schedule     RFS     (Rev.   5-3-12)
              APPENDIX E

               SCHEDULE 2
LETTER OF INTENT TO PERFORM AS AN ACDBE
             RFS No. PB 12-13
                                          SCHEDULE 2
   LETTER OF INTENT TO PERFORM AS AN AIRPORT CONCESSION DISADVANTAGED BUSINESS ENTERPRISE*

                                                      RFS #PB 12-13
                                          PAY TELEPHONE CONCESSION AGREEMENT
                                           PALM BEACH INTERNATIONAL AIRPORT


Name of Respondent: ______________________________________________________________________________

Name of ACDBE Firm: ______________________________________________________________________________

The undersigned is certified as an Airport Concession Disadvantaged Business Enterprise by Palm Beach County or the State
of Florida’s Unified Certification Program. Check one or more classifications as applicable:

□ Black                     □ Hispanic          □ Women                □ Other (Please Specify) _______

□ Prime Contractor          □ Subcontractor     □ Manufacturer         □ Supplier      □ Joint Venture

The undersigned ACDBE firm is prepared to perform the following described work in connection with the above-referenced
contract (specify in detail the particular work and/or parts thereof to be performed):

_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________

The estimated value of the work is ________________________% of Respondent’s estimated annual gross revenues.
                                  (ACDBE Firm’s Quote)

The undersigned will enter into a formal agreement for work with you conditioned upon your execution of a contract with Palm
Beach County.

If the undersigned intends to subcontract any portion of the work described above to another subcontractor, please
complete the following:

________________________________                _______________________% □ ACDBE Certified
          (Name of Subcontractor)               (Percentage of work subcontracted) □ Non-ACDBE

________________________________                _______________________% □ ACDBE Certified
          (Name of Subcontractor)               (Percentage of work subcontracted) □ Non-ACDBE


The undersigned affirms that it has the resources necessary to perform the work described above without subcontracting the
work to another subcontractor, except as noted above. The undersigned ACDBE firm understands that the provision of this
form to the Respondent does not prevent the subcontractor from providing quotations to other Respondents.

                                                                 ___________________________________
                                                                     Printed Name of ACDBE Firm

                                                                 By: _______________________________
                                                                        Signature

                                                                 Date: ______________________________




*This form must be submitted for each ACDBE firm listed on Schedule 1, “List of Proposed ACDBE Firms”.

								
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