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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