REQUEST FOR PROPOSAL RFP 16-033 Digital Displays · PDF fileArgyle ISD Business Office 800...

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Argyle ISD Business Office 800 Eagle Drive Argyle, TX 76226 Phone (940) 464-7241 Fax (940) 464- 7297 REQUEST FOR PROPOSAL RFP 16-033 – Digital Displays Argyle ISD is soliciting sealed proposals for digital displays. Enclosed are the Terms and Conditions and Specifications for submitting your bid. Vendors are instructed to be fully informed on all information contained in this packet. To be considered in this RFP, the vendor must submit a sealed original proposal marked: RFP 16-033 Digital Displays Proposals should be delivered/mailed to: Business Office Argyle ISD 800 Eagle Drive Argyle, TX 76226 Proposals must reach the Business Office by: 10:00 AM on March 9, 2016 Faxed proposals will not be considered. All prices to exclude sales tax. All prices are to be inclusive of inside delivery, installation, trash removal, and shipping charges. It is the Vendor’s responsibility to make sure their proposal is received by Argyle ISD on time. Time of receipt will be determined by the District’s clock. The proposals will be opened at the time and date listed above. Any proposal received after the above-specified time and date may not be considered. Proposals may be withdrawn upon written request from vendor if such request is received prior to the specified time of opening. Argyle ISD reserves the right to reject any or all proposals, to waive any proposal irregularities, and to accept the proposal or multiple proposals that are deemed to be in the best interest of Argyle ISD. Any questions or concerns regarding this proposal shall be directed to Greg Royar, Technology Director, by email at [email protected].

Transcript of REQUEST FOR PROPOSAL RFP 16-033 Digital Displays · PDF fileArgyle ISD Business Office 800...

Page 1: REQUEST FOR PROPOSAL RFP 16-033 Digital Displays · PDF fileArgyle ISD Business Office 800 Eagle Drive Argyle, TX 76226 Phone (940) 464-7241 Fax (940) 464- 7297 REQUEST FOR PROPOSAL

Argyle ISD Business Office

800 Eagle Drive Argyle, TX 76226

Phone (940) 464-7241 Fax (940) 464- 7297

REQUEST FOR PROPOSAL

RFP 16-033 – Digital Displays

Argyle ISD is soliciting sealed proposals for digital displays. Enclosed are the Terms and Conditions and Specifications for submitting your bid. Vendors are instructed to be fully informed on all information contained in this packet. To be considered in this RFP, the vendor must submit a sealed original proposal marked:

RFP 16-033 Digital Displays

Proposals should be delivered/mailed to:

Business Office Argyle ISD

800 Eagle Drive Argyle, TX 76226

Proposals must reach the Business Office by:

10:00 AM on March 9, 2016

Faxed proposals will not be considered. All prices to exclude sales tax. All prices are to be inclusive of inside delivery, installation, trash removal, and shipping charges. It is the Vendor’s responsibility to make sure their proposal is received by Argyle ISD on time. Time of receipt will be determined by the District’s clock. The proposals will be opened at the time and date listed above. Any proposal received after the above-specified time and date may not be considered. Proposals may be withdrawn upon written request from vendor if such request is received prior to the specified time of opening. Argyle ISD reserves the right to reject any or all proposals, to waive any proposal irregularities, and to accept the proposal or multiple proposals that are deemed to be in the best interest of Argyle ISD. Any questions or concerns regarding this proposal shall be directed to Greg Royar, Technology Director, by email at [email protected].

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Argyle ISD Business Office

800 Eagle Drive Argyle, TX 76226

Phone (940) 464-7241 Fax (940) 464- 7297

Section One – Scope of Work

Delivery Items must be delivered and install per District schedule stated in specifications. Delivery shall be made between the hours of 8:30 AM and 11:30 AM or 1:30 and 3:30 PM, Monday through Thursday except on school holidays. Deliveries will be staggered as per district instructions to allow for installation in phases. Vendor will be required to send in writing delivery dates for their FFE shipments two weeks in advance to allow for proper staging of shipments. Vendor personnel must be onsite during deliveries. Shipments will be refused unless vendor personnel is present. Vendor personnel will be required to provide their own equipment for unloading and installation of product. All floors and doors need to be protected and non-marring wheels must be used. The right is reserved to reject incorrect or damaged shipments.

Installation Vendors are required to have onsite personnel throughout their installation time period. A daily work schedule is to be provided to onsite district personnel.

Installers are required to notify designated district personnel of any freight damage and shortages in writing on a vendor provided form immediately. Installers are to coordinate the unpacking, assembly and installation of items in all spaces. Do not leave work areas unattended. Installer is to ensure all new items are assembled according to manufacturer’s instructions and set in proper place. Trash is to be removed upon completion of areas of work and no less than twice weekly. All packing materials are to be removed completely from assembled products. Installers may not be pulled off the job and leave an incomplete installation or leave trash laying around due to the uncompleted job or the district reserves the right to pay to have the trash removed and deduct the cost from the vendor’s invoice. Work areas need to be kept clean, picked up and free of food, drinks, etc.

Second floor deliveries (if applicable) – Installation prices should include labor to have deliveries to the second floor by use of the stairs. Installation will include placement of all items in the specified room or area as designated by proposal specifications or the district. This scope of work includes complete assembly of all small “Ready To Assemble” products.

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Argyle ISD Business Office

800 Eagle Drive Argyle, TX 76226

Phone (940) 464-7241 Fax (940) 464- 7297

The onsite district supervisor will complete a walkthrough of all items of each vendor and sign-off on the product per room list before the vendor is considered to be completed on the job.

Regular hours for installation will be observed from 8:00 – 5:00 unless otherwise approved by the district. PRICING All pricing of product shall include delivery, installation, shipping, and trash removal from the premises in a timely manner.

Section Two – Standard Terms and Conditions

Seller of Package Goods: Seller will package goods in accordance with good commercial practice. Each shipping container shall be clearly and permanently packed as follows: (a) Seller's name and address; (b) Consignee's name, address and purchase order number (c) Container number and total number of containers, e.g. box 1 of 3 boxes; and (d) the number of the container bearing the packing slip. Seller shall bear cost of packaging unless otherwise provided. Goods shall be suitably packed to secure lowest transportation costs and to conform to requirements of common carriers and any applicable specifications. Buyer's count or weight shall be final and conclusive on shipments not accompanied by packing lists. Title and Risk of Loss: The title and risk of loss of the goods shall not pass to Buyer until Buyer actually receives and takes possession of the goods at the point or points of delivery. Delivery Terms and Transportation Charges: F.O.B. Destination Freight Prepaid unless terms are specified otherwise in proposal. Buyer agrees to reimburse Seller for transportation costs in the amount specified in Seller's proposal or actual costs, whichever is lower, if the quoted delivery terms do not include transportation costs, provided Buyer shall have the right to designate what method of transportation shall be used to ship the goods. Place of Delivery: The place of delivery shall be that set forth on the purchase order. The terms of this agreement are "no arrival, no sale." Invoices and Payments: Seller shall submit separate invoices, in duplicate, on each purchase order after each delivery and completed installation. Invoices shall indicate the purchase order number and shall be itemized. A copy of the bill of lading, and the freight weight bill when applicable, should be attached to the invoice.

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Argyle ISD Business Office

800 Eagle Drive Argyle, TX 76226

Phone (940) 464-7241 Fax (940) 464- 7297

Mail to: Argyle ISD

Accounts Payable Department 800 Eagle Drive

Argyle, TX 76226 Payment shall not be due until the above instruments are submitted after delivery, installation, and inspection are complete. Suppliers should keep the Finance Department advised of any changes in your remittance addresses. DO NOT include Federal Excise, State, or City Sales Tax. School District shall furnish tax exemption certificate, if required. Warranty Products: Seller shall not limit or exclude any implied warranties. Any attempt to do so shall render this contract null and void at the option of the Buyer. Seller warrants that:

a. The goods to be delivered hereunder shall be in full conformity to the specifications, drawings, and descriptions listed in the packet, and to sample(s) furnished by Seller, if any. Further, it is agreed that this warranty shall survive acceptance of delivery and payment for the goods and that the Seller agrees to bear the cost of inspection and/or testing all goods rejected.

b. That the goods to be delivered hereunder will not infringe on any valid patent, trademark, tradename, or copyright, and that the Seller will, at no expense to the Buyer, defend any and all actions or suits charging such infringement against the Buyer, its agents and/or employees, in the event of any action or suit.

c. That the goods to be delivered hereunder will be manufactured, sold, and/or installed in compliance with the provision of all applicable Federal, State, and Local laws, ordinances, statutes, regulations, and/or policies.

d. That nothing contained herein shall exclude or affect the operation of any implied warranties otherwise arising in favor of the Buyer.

e. In event of conflict between specifications, drawings, and descriptions, the specifications shall govern.

Safety – Warranty: Seller warrants that the product sold to Buyer shall conform to the standard promulgated by the U.S. Department of Labor under the Occupational Safety Health Act of 1970. In the event the product does not conform to OSHA standards, Buyer may return the product for correction or replacement at the Seller’s expense. The “Hazardous Communications Act”, commonly known as the “Texas Right to Know Act”, states that a Seller must provide to the Buyer, with each delivery, material safety data sheets as is applicable to hazardous substances defined in this Act.

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Argyle ISD Business Office

800 Eagle Drive Argyle, TX 76226

Phone (940) 464-7241 Fax (940) 464- 7297

Right of Inspection: Buyer shall have the right to inspect the goods at delivery point before accepting them. The Buyer reserves the right to:

a. Inspect articles delivered and to return those which do not meet specification or reasonable standards of quality.

b. Reject articles shipped contrary to instructions or in containers which do not meet recognized standards.

c. The Buyer may return rejected articles or excess merchandise (or may hold the articles subject to the Seller’s order) and may, at Seller’s risk and expense, in either event, charge Seller with the cost of shipping, unpacking, inspecting, repacking, re-shipping, and other like expenses.

Cancellation: Buyer shall have the right to cancel for default all or any part of the undelivered portion of this order if Seller breaches any of the terms hereof including warranties of Seller or if the Seller becomes insolvent or commits acts of bankruptcy. Such right of cancellation is in addition to and not in lieu of any other remedies which Buyer may have in law or equity. Termination: The performance of work under this order may be terminated in whole or in part by the Buyer in accordance with this provision. Termination of work there under shall be effected by the delivery to the Seller of a "Notice of Termination" specifying the extent to which performance of work under the order is terminated and the date upon which such termination becomes effective. Such right of termination is in addition to and not in lieu of rights of Buyer set forth herein. Modifications: This contract can be modified or rescinded only in writing, signed by both parties to the contract or their duly authorized agents. Late Proposals: Proposal or withdrawals thereof received after the time set for opening will not be considered. Withdrawal of Sealed Proposals: Proposals may be withdrawn prior to the time of proposal opening by written notice only. Severability: If any section, subsection, paragraph, sentence, clause phrase, or word of these specifications shall be held invalid, such holding shall not affect the remaining portions of these specifications and it is hereby declared that such remaining portions would have been included in these specifications as though the invalid portion had been omitted. Hold Harmless: Seller shall indemnify and hold Argyle ISD harmless for all claims of personal injury, death, and /or property damage rising from any and all causes whatsoever, resulting directly or indirectly from Seller’s performance. Seller shall procure and maintain, in respect to

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Argyle ISD Business Office

800 Eagle Drive Argyle, TX 76226

Phone (940) 464-7241 Fax (940) 464- 7297

subject matter of this proposal, appropriate insurance coverage including, as minimum, public liability and property damage, and worker’s compensation with adequate limits to cover Seller’s liability as may arise directly or indirectly from work performed under terms of this bid. Where deemed appropriate by the Buyer, the limits of coverage will be included in the Special Instructions/Specifications. Certificate of such coverage must be provided to the Buyer with the proposal packet. Waiver of Subrogation: By virtue of acceptance of this contract, both Seller and insurance carrier waive any rights whatsoever with regard to subrogation against Argyle ISD as an indirect party to any suit arising out of personal or property damage resulting from Seller’s performance under this contract. Award: Action on all proposals shall be taken within sixty (60) calendar days from the date and time of opening proposals and the price must remain firm for this period of time. The acceptance of an offer will be notice in writing signed by a duly-authorized representative. The acceptance of an offer shall bind the successful Seller(s) to execute the contract and be responsible for liquidated damages as provided herein. Buyer reserves the right to award multiple proposals as deemed to be in the best interest of the District. The Seller(s) whose offer is accepted shall execute the contract and all related documents within ten (10) days after the presentation of the contract for signature. The contract and related documents must be signed by an authorized officer of the Seller are received by the Buyer. Failure to execute the contract and related documents within the time specified may constitute a breach of this Agreement affecting the acceptance of the offer. Buyer reserves the right to award this contract in accordance with the laws of the State of Texas, to reject any or all proposals, to waive any proposal irregularities, and to accept any proposal(s) deemed to be in the best interest of the Buyer. Non-Appropriation of Funds: This agreement is subject to the appropriation of funds by Argyle ISD in its budget adopted for any fiscal year for the specific purpose of making payments pursuant to this agreement for that fiscal year. The obligation for Argyle ISD pursuant to this agreement in effect shall constitute a current expense of Argyle ISD for that fiscal year only and shall not constitute an indebtedness of Argyle ISD beyond that fiscal year. Nothing contained herein shall constitute an indebtedness of Argyle ISD beyond that fiscal year. Nothing contained herein shall constitute a pledge by Argyle ISD of any taxes or monies other than monies lawfully appropriated in any fiscal year. In the event of non-appropriation of funds in any fiscal year to make payments pursuant to this Agreement, the Agreement may be terminated.

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Argyle ISD Business Office

800 Eagle Drive Argyle, TX 76226

Phone (940) 464-7241 Fax (940) 464- 7297

Section Three – Submission of Proposal

1. Each Seller is expected to examine the specifications and all instructions. Failure to do so will be at the vendor's risk. However, Argyle ISD reserves the right to reject any or all proposals and to waive minor irregularities in proposal preparation.

2. Each vendor shall furnish the information required on the District Proposal forms. Deviations to

the Standard Conditions and/or Specific Specifications shall be conspicuously noted in writing by the Seller and shall be included with the proposal.

3. Erasure or other changes/corrections must be initialed by person submitting the proposal.

4. Unit price and extended price for each item offered will be recorded in proper columns on the

proposal form. If there is a discrepancy between the unit cost and the total price, the unit cost will stand as the offered price.

5. Proposals shall be enclosed in sealed envelopes addressed per instructions, with the name and

address of the Seller, the title of the proposal, and the date and hour of opening on the face of the envelope.

6. The Seller may respond to all or part of the proposal unless otherwise instructed.

7. Faxed proposals will not be accepted by the District. Responses must be typed or printed on

letter size (8-1/2” x 11”) paper. Fold out materials may be provided if necessary.

8. NUMBER OF COPIES – Submit two (2) copies of the entire submission. This shall include the original, with original signatures and one copy.

9. Any deviations from the proposal (CSP) specifications must be noted in detail with deviations

from specs in writing along with literature highlighting alternate products submitted for consideration. Failure to do so may cause the proposal to be rejected. The district may require actual samples of alternate bid products.

10. The District will consider the following for this award:

a. The soundness of the vendor’s approach to the complete delivery and installation of the equipment as specified.

b. The quality of the vendor’s goods or services. c. The ability of the vendor to have the complete awarded equipment in place according to

the time schedule given by the district. d. All additional criteria listed in the Standard Terms and Conditions, “Award Section” of

this document.

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Argyle ISD Business Office

800 Eagle Drive Argyle, TX 76226

Phone (940) 464-7241 Fax (940) 464- 7297

Section Four – Award of Contract

The district reserves the right to accept or reject any or all proposals or portion of a proposal, to slightly vary proposal quantities and to accept the proposal or multiple proposals that are determined to be the most favorable to the district. As provided in Education Code, Subchapter B, Sec.44.031 (b), the district may consider the following in choosing the proposal that will provide the best advantage to the district:

1. Evaluative Criteria and Relative Weights: The evaluative criteria that may be considered by the District in its decision to award a contract are as follows:

a. Purchase price. b. The reputation of the vendor and the vendor's goods and services. c. The quality of the vendor's goods and services. d. The extent to which the goods or services meet the District's needs. e. The vendor's past relationship with the District. f. The impact on the ability of the District to comply with laws relating to

historically underutilized businesses. g. The total long-term cost to the District to acquire the goods or services. h. Any other relevant factor that a private business entity would consider in

selecting a vendor.

2. The District reserves the right to reject any or all sealed proposals and to waive informalities and minor irregularities in sealed proposals received. Failure to observe the District’s instructions and conditions will constitute grounds for rejection of a sealed proposal or removal from District's vendor list.

3. The District may award any item or group of items of any proposal, unless the Seller

qualifies their proposal by specific limitations, i.e. "All or None." Furthermore, the District reserves the right to make an award on any item for a quantity greater than the quantity offered upon at the unit price offered unless the Seller specifies otherwise in his/her proposal.

4. In some instances it is to the advantage of the District to award the entire proposal to

one Seller. Vendor may propose and “all-or-none” or “lump sum” price proposal for the District’s review.

5. It is understood and agreed that the District reserves the right to increase or decrease

quantities upon the time of order.

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Argyle ISD Business Office

800 Eagle Drive Argyle, TX 76226

Phone (940) 464-7241 Fax (940) 464- 7297

6. Any catalog, brand name or manufacturer’s reference used in the proposal is descriptive, not restrictive, it is intended to indicate type and quality desired. Substitutions (alternate product submission) will be accepted only if the item is an approved equal or of superior quality. The district reserves the right to make this determination and is to be furnished with a sample of any item offered upon request. When offering items with trade names and/or numbers other than those indicated in the proposal specifications, this information and other pertinent data must be provided or the proposal will not be considered. Vendor guarantees product offered to meet or exceed specifications identified in this proposal invitation. Substitution manufacturer and product number is to be listed directly below the item number on the included proposal spreadsheet.

Page 10: REQUEST FOR PROPOSAL RFP 16-033 Digital Displays · PDF fileArgyle ISD Business Office 800 Eagle Drive Argyle, TX 76226 Phone (940) 464-7241 Fax (940) 464- 7297 REQUEST FOR PROPOSAL

Argyle ISD Business Office

800 Eagle Drive Argyle, TX 76226

Phone (940) 464-7241 Fax (940) 464- 7297

RFP Response Checklist

To be considered for award of this proposal, all pages requiring signature must be completed with all requested information, SIGNED and RETURNED sealed in an envelope or other appropriate package adequate to conceal and contain the contents prior to the RFP date and time.

o Completed – Authorization Agreement

o Completed – Felony Conviction Notification

o Completed – Non-Collusion Statement

o Completed – References

o Completed – Conflict of Interest Questionnaire

o Completed – W-9 Form

o Completed – RFP Specification

o Completed – RFP Evaluation

o Included – Certificate of Insurance

Page 11: REQUEST FOR PROPOSAL RFP 16-033 Digital Displays · PDF fileArgyle ISD Business Office 800 Eagle Drive Argyle, TX 76226 Phone (940) 464-7241 Fax (940) 464- 7297 REQUEST FOR PROPOSAL

Argyle ISD Business Office

800 Eagle Drive Argyle, TX 76226

Phone (940) 464-7241 Fax (940) 464- 7297

AUTHORIZATION AGREEMENT COMPANY ADDRESS ZIP CODE TELEPHONE FAX NUMBER AUTHORIZED REPRESENTATIVE Please type or print name PLEASE NOTE THE CORRECT ADDRESS FOR MAILING OF PURCHASE ORDER: PLEASE NOTE THE CORRECT ADDRESS FOR PAYMENT REMITTANCE: PLEASE GIVE NAME, ADDRESS, AND TELEPHONE NUMBER OF LOCAL SALES REPRESENTATIVE: IF YOUR COMPANY OFFERS A CASH DISCOUNT FOR PROMPT PAYMENT OF INVOICES, PLEASE INDICATE THE TERMS BELOW. TERMS - % DOES ANYONE EMPLOYED BY YOUR COMPANY HAVE AN IMMEDIATE RELATIVE CURRENTLY EMPLOYED WITH ARGYLE ISD? __________ IF SO, LIST NAME(S) OF EMPLOYEE(S):_________________________________________ ________________________________________________________________________ The undersigned, in submitting this RFP and endorsement of same, represents that he/she is authorized to obligate his/her firm, that he/she is an equal opportunity employer and will not discriminate with regard to race, color, religion, national origin, sexual orientation, or age or disability unrelated to job

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Argyle ISD Business Office

800 Eagle Drive Argyle, TX 76226

Phone (940) 464-7241 Fax (940) 464- 7297

performance of this RFP; and that he/she has read this entire RFP package, is aware of the covenants contained herein and will abide by and adhere to the expressed requirements in all sections of this RFP. The undersigned bidder’s agent hereby proposes and agrees to furnish product or provide service in strict compliance with the specifications and conditions and at the prices quoted. SIGNED ______ DATE ADDENDUM ACKNOWLEDGEMENT Receipt is hereby acknowledged of the following addendum (list addendum received if applicable): SIGNED ______ DATE

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Argyle ISD Business Office

800 Eagle Drive Argyle, TX 76226

Phone (940) 464-7241 Fax (940) 464- 7297

FELONY CONVICTION NOTIFICATION

The Texas Education Code, Section 44.034(a) states that 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 of the business entity has been convicted of a felony. The notice must include a general description of the conduct resulting in the conviction of the felony. Furthermore, Section 44.034(b) states that 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. Lastly, Section 44.034 (c) states that this section does not apply to a publicly held corporation. ( ) My firm is a publicly held corporation, therefore this requirement is not applicable. ( ) My firm is not owned nor operated by anyone who has been convicted of a felony. ( ) My firm is owned or operated by the following individual(s) who has/have been convicted of a felony: Name: ___________________________________________________________________ Description of conduct resulting in a felony: _____________________________________ _________________________________________________________________________ Name: ___________________________________________________________________ Description of conduct resulting in a felony: _____________________________________ _________________________________________________________________________ Name: ___________________________________________________________________ Description of conduct resulting in a felony: _____________________________________ _________________________________________________________________________ I, the undersigned agent for the firm named below, certify that the information concerning notification of felony conviction has been received by me and that the information furnished above is true to the best of my knowledge. Vendor’s Name: _______________________________________________________________ Authorized Company Official’s Name: _____________________________________________ Authorized Company Official’s Title: ______________________________________________ _____________________________ ___________________________________ Date Signature

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Argyle ISD Business Office

800 Eagle Drive Argyle, TX 76226

Phone (940) 464-7241 Fax (940) 464- 7297

NON-COLLUSIVE BIDDING CERTIFICATE By submission of this bid or proposal, the vendor certifies that:

a) This bid or proposal has been independently arrived at without collusion with any other vendor/bidder or with any competitor;

b) This bid or proposal has not been knowingly disclosed and will not knowingly be disclosed, prior

to the opening of bids or proposals for this project, to any other bidder, competitor or potential competitor;

c) No attempt has been or will be made to induce any other person, partnership or corporation to

submit or not to submit a bid or proposal;

d) The person signing this bid or proposal certifies that he has fully informed himself regarding the accuracy of the statements contained in this certification under the penalties being applicable to the bidder as well as to the person signing in its behalf;

e) THE FAILURE TO SIGN THIS CERTIFICATE MAY BE CAUSE FOR YOUR BID OR PROPOSAL TO BE

REJECTED. Company Name Authorized Signature Title

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Argyle ISD Business Office

800 Eagle Drive Argyle, TX 76226

Phone (940) 464-7241 Fax (940) 464- 7297

REFERENCES Company Name: ______________________________ Address: ______________________________ ______________________________ ______________________________ Business Phone: _______________________________ Fax: ________________________ Contact Person: _______________________________ Email: _______________________ Description of project or work completed: __________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Company Name: ______________________________ Address: ______________________________ ______________________________ ______________________________ Business Phone: _______________________________ Fax: ________________________ Contact Person: _______________________________ Email: _______________________ Description of project or work completed: __________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Company Name: ______________________________ Address: ______________________________ ______________________________ ______________________________ Business Phone: _______________________________ Fax: ________________________ Contact Person: _______________________________ Email: _______________________ Description of project or work completed: __________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

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Adopted 06/29/2007

FORM CIQ

OFFICE USE ONLYThis questionnaire reflects changes made to the law by H.B. 1491, 80th Leg., Regular Session.

This questionnaire is being filed in accordance with Chapter 176, Local Government Code

by a person who has a business relationship as defined by Section 176.001(1-a) with a local

governmental entity and the person meets requirements under Section 176.006(a).

By law this questionnaire must be filed with the records administrator of the local governmental

entity not later than the 7th business day after the date the person becomes aware of facts

that require the statement to be filed. See Section 176.006, Local Government Code.

A person commits an offense if the person knowingly violates Section 176.006, Local

Government Code. An offense under this section is a Class C misdemeanor.

CONFLICT OF INTEREST QUESTIONNAIREFor vendor or other person doing business with local governmental entity

Check this box if you are filing an update to a previously filed questionnaire.

(The law requires that you file an updated completed questionnaire with the appropriate filing authority not

later than the 7th business day after the date the originally filed questionnaire becomes incomplete or inaccurate.)

Name of person who has a business relationship with local governmental entity.1

2

3

Date Received

Name of local government officer with whom filer has employment or business relationship.

Name of Officer

This section (item 3 including subparts A, B, C & D) must be completed for each officer with whom the filer has an

employment or other business relationship as defined by Section 176.001(1-a), Local Government Code. Attach additional

pages to this Form CIQ as necessary.

A. Is the local government officer named in this section receiving or likely to receive taxable income, other than investment

income, from the filer of the questionnaire?

Yes No

B. Is the filer of the questionnaire receiving or likely to receive taxable income, other than investment income, from or at the

direction of the local government officer named in this section AND the taxable income is not received from the local

governmental entity?

Yes No

C. Is the filer of this questionnaire employed by a corporation or other business entity with respect to which the local

government officer serves as an officer or director, or holds an ownership of 10 percent or more?

Yes No

D. Describe each employment or business relationship with the local government officer named in this section.

Signature of person doing business with the governmental entity Date

4