0002 RFQ - SOI Structural Engineering Assessment - Classroom Building WW2 Airbase

COMPANY INFORMATION
Company Name: ____________________________________________
Address: ___________________________________________________
City, State, Zip: _____________________________________________
Phone: ____________________________________________________
Fax: ______________________________________________________
Email: _____________________________________________________
Rep. Printed Name: __________________________________________
(Type or Print Legibly)
Rep. Signature/Title: _________________________________________
Tax ID#: ____________________ or SS # ______________________
CITY OF DOUGLAS, GA
REFERENCE SHEET
NAME: _________________________________ PHONE: _____________________
NAME: _________________________________ PHONE: _____________________
NAME: _________________________________ PHONE: _____________________

INSURANCE SPECIFICATIONS PAGE:
Insurance is required on projects being done on City property as specified on the Request for Quote unless
waived by City of Douglas. A Certificate of Insurance made out to City of Douglas must be furnished
before any work can begin.
Please provide the following information.
Liability Insurance coverage*:
Bodily Injury $_____________________________________________________
(Minimum $1,000,000. required)
Property Damage $__________________________________________________
(Minimum $1,000,000. required)
Workman's Compensation $___________________________________________
(Statutory coverage as required by the State of Georgia.)
*Liability coverage must be provided to include premises, operations, products and completed
operations.
* Subcontractors - It shall be the responsibility of the selected bidder to ensure that all
subcontractors comply with the same insurance requirements referenced above.

Private Employer Affidavit Pursuant To O.C.G.A. 36-60-6(d)
By executing this affidavit under oath, the undersigned private employer verifies one of the following with
respect to its application for a business license, occupational tax certificate, or other document required to operate a
business as referenced in O.C.G.A. 36-60-6(d):
Section 1. Please check only one:
(A) ________ On January 1st of the below-signed year, the individual, firm, or
corporation employed more than ten (10) employees1.
*** If you select Section 1(A), please fill out Section 2 and then execute below.
(B) ________ On January 1st of the below-signed year, the individual, firm, or
corporation employed ten (10) or fewer employees.
*** If you select Section 1(B), please skip Section 2 and execute below.
Section 2.
The employer has registered with and utilizes the federal work authorization program in accordance with the
applicable provisions and deadlines established in O.C.G.A. 36-60-6. The undersigned private employer also
attests that its federal work authorization user identification number and date of authorization are as follows:
__________________________________
Name of Private Employer
__________________________________
Federal Work Authorization User Identification Number
__________________________________ Date of
Authorization
---------------------------------------------------------------------------------------------------------------------
I hereby declare under penalty of perjury that the foregoing is true and correct.
Executed on ______, ___, 20___ in _____ (city), ______ (state).
__________________________________
Signature of Authorized Officer or Agent
__________________________________
Printed Name and Title of Authorized Officer or Agent
SUBSCRIBED AND SWORN BEFORE ME
ON THIS THE ______ DAY OF ______________, 20___.
_______________________________________________
NOTARY PUBLIC
My Commission Expires: __________________________
1 To determine the number of employees for purposes of this affidavit, a business must count its total number of employees company-
wide, regardless of the city, state, or country in which they are based, working at least 35 hours a week.

Certification of "No Employees" under O.C.G.A. 13-10-91(b)(5)
By signing this form, the undersigned contractor verifies it has no employees and has no plans to hire
employees for the purpose of executing the contract (named below) for the Georgia Department of Audits and
Accounts. The contractor agrees to provide the Georgia Department of Audits and Accounts with a copy of a
state issued driver's license or a state issued identification card as proof that he/she is authorized to perform the
work related to this contract. Failure to submit this signed statement and/or provide the required license or
identification card would prohibit the Georgia Department of Audits and Accounts from acquiring any
additional or future services with you or your company.
Name of Contractor
Name of Project/Contract
I hereby declare under penalty of perjury that the foregoing is true and correct.
Executed on __________, _____, 20__ in _______________(city), _____(state).
___________________________________
Signature of Authorized Officer or Agent
___________________________________
Printed Name and Title of Authorized Officer or Agent
Reminder: Copy of Driver's License Required

SECURITY AND IMMIGRATION COMPLIANCE
Contractor Affidavit under O.C.G.A. 13-10-91(b) (1)
By executing this affidavit, the undersigned contractor verifies its compliance with O.C.G.A. 13-10-91, stating
affirmatively that the individual, firm or corporation which is engaged in the physical performance of services on behalf
of GEORGIA DEPARTMENT OF HUMAN SERVICES has registered with, is authorized to use and uses the federal
work authorization program commonly known as E-Verify, or any subsequent replacement program, in accordance with
the applicable provisions and deadlines established in O.C.G.A. 13-10-91. Furthermore, the undersigned contractor
will continue to use the federal work authorization program throughout the contract period and the undersigned
contractor will contract for the physical performance of services in satisfaction of such contract only with subcontractors
who present an affidavit to the contractor with the information required by O.C.G.A. 13-10-91(b). Contractor hereby
attests that its federal work authorization user identification number and date of authorization are as follows:
_____________________________________
Federal Work Authorization User Identification Number
_____________________________________
Date of Authorization
_________________________________
Name of Contractor
_____________________________________
Name of Project
GEORGIA DEPARTMENT OF HUMAN SERVICES
Name of Public Employer
I hereby declare under penalty of perjury that the foregoing is true and correct.
Executed on , 20 in (city), (state).
_________________________________
Signature of Authorized Officer or Agent
__________________________________
Printed Name and Title of Authorized Officer or Agent
SUBSCRIBED AND SWORN BEFORE ME
ON THIS THE DAY OF , 20 .
_________________________________
NOTARY PUBLIC
My Commission Expires:
_________________________________

SECURITY AND IMMIGRATION COMPLIANCE
Subcontractor Affidavit under O.C.G.A. 13-10-91(b) (3)
By executing this affidavit, the undersigned subcontractor verifies its compliance with O.C.G.A. 13-10-91, stating
affirmatively that the individual, firm or corporation which is engaged in the physical performance of services under a
contract with on behalf of GEORGIA DEPARTMENT OF
HUMAN SERVICES has registered with, is authorized to use and uses the federal work authorization program
commonly known as E-Verify, or any subsequent replacement program, in accordance with the applicable provisions
and deadlines established in O.C.G.A. 13-10-91. Furthermore, the undersigned subcontractor will continue to use the
federal work authorization program throughout the contract period and the undersigned subcontractor will contract for
the physical performance of services in satisfaction of such contract only with sub-subcontractors who present an
affidavit to the subcontractor with the information required by O.C.G.A. 13-10-91(b). Additionally, the undersigned
subcontractor will forward notice of the receipt of an affidavit from a sub-subcontractor to the contractor within five
business days of receipt. If the undersigned subcontractor receives notice that a sub-subcontractor has received an
affidavit from any other contracted sub-subcontractor, the undersigned subcontractor must forward, within five business
days of receipt, a copy of the notice to the contractor. Subcontractor hereby attests that its federal work authorization
user identification number and date of authorization are as follows:
_________________________________
Federal Work Authorization User Identification Number
_________________________________
Date of Authorization
_________________________________
Name of Subcontractor
_________________________________
Name of Project
_________________________________
Name of Public Employer
I hereby declare under penalty of perjury that the foregoing is true and correct.
Executed on ___________________, 20_____ in (city), (state).
_________________________________
Signature of Authorized Officer or Agent
_______________________________
Printed Name and Title of Authorized Officer or Agent
SUBSCRIBED AND SWORN BEFORE ME
ON THIS THE DAY OF , 20 .
_________________________________
NOTARY PUBLIC
My Commission Expires:
_________________________________

SECURITY AND IMMIGRATION COMPLIANCE
Sub-subcontractor Affidavit under O.C.G.A. 13-10-91(b) (4)
By executing this affidavit, the undersigned sub-subcontractor verifies its compliance with O.C.G.A. 13-10-91, stating
affirmatively that the individual, firm or corporation which is engaged in the physical performance of services under a
contract for (name of subcontractor or sub-subcontractor with whom such sub-subcontractor has privity of contract) and
_____________________________________________ on behalf of GEORGIA DEPARTMENT OF HUMAN
SERVICES has registered with, is authorized to use and uses the federal work authorization program commonly known
as E-Verify, or any subsequent replacement program, in accordance with the applicable provisions and deadlines
established in O.C.G.A. 13-10-91. Furthermore, the undersigned sub-subcontractor will continue to use the federal
work authorization program throughout the contract period and the undersigned sub-subcontractor will contract for the
physical performance of services in satisfaction of such contract only with sub-subcontractors who present an affidavit
to the sub-subcontractor with the information required by O.C.G.A. 13-10-91(b). The undersigned sub-subcontractor
shall submit, at the time of such contract, this affidavit to (name of subcontractor or sub-subcontractor with whom such
sub-subcontractor has privity of contract). Additionally, the undersigned sub-subcontractor will forward notice of the
receipt of any affidavit from a sub-subcontractor to (name of subcontractor or sub-subcontractor with whom such sub-
subcontractor has privity of contract). Sub-subcontractor hereby attests that its federal work authorization user
identification number and date of authorization are as follows:
_________________________________
Federal Work Authorization User Identification Number
_________________________________
Date of Authorization
_________________________________
Name of Sub-subcontractor
_________________________________
Name of Project
_________________________________
Name of Public Employer
I hereby declare under penalty of perjury that the foregoing is true and correct.
Executed on , 20 in (city), (state).
_________________________________
Signature of Authorized Officer or Agent
_______________________________
Printed Name and Title of Authorized Officer or Agent
SUBSCRIBED AND SWORN BEFORE ME
ON THIS THE DAY OF , 20 .
_________________________________
NOTARY PUBLIC
My Commission Expires:
_________________________________

Appendix A
During the performance of this contract, the contractor/consultant, for itself, its assignees and successors in
interest (hereinafter referred to as the "contractor") agrees as follows:
Compliance with Regulations
The contractor shall comply with the Regulations relative to non-discrimination in federally assisted programs
of United States Department of Transportation (USDOT), Title 49, Code of Federal Regulations, part 21, as
they may be amended from time to time, (hereinafter referred to as the Regulations), which are herein
incorporated by reference and made a part of this contract.
Non-discrimination
The contractor, with regard to the work performed by it during the contract, shall not discriminate on the
grounds of race, color, sex, or national origin in the selection and retention of sub-contractors, including
procurement of materials and leases of equipment. The contractor shall not participate either directly or
indirectly in the discrimination prohibited by Section 21.5 of the Regulations, including employment practices
when the contract covers a program set forth in Appendix B of the Regulations.
Solicitations for Sub-contracts, Including Procurement of Materials
and Equipment
In all solicitations either by competitive bidding or negotiations made by the contractor for work to be
performed under a sub-contract, including procurement of materials or leases of equipment, each potential sub-
contractor or supplier shall be notified by the contractor of the contractor's obligations under this contract and
the Regulations relative to nondiscrimination on the grounds of race, color, sex, or national origin.
Information and Reports
The contractor shall provide all information and reports required by the Regulations or directives issued
pursuant thereto, and shall permit access to its books, records, accounts, other sources of information, and its
facilities as may be determined by the contracting agency or the appropriate federal agency to be pertinent to
ascertain compliance with such Regulations, orders and instructions. Where any information required of a
contractor is in the exclusive possession of another who fails or refuses to furnish this information, the
contractor shall so certify to GDOT or the USDOT as appropriate, and shall set forth what efforts it has made to
obtain the information
Sanctions for Non-compliance
In the event of the contractor's non-compliance with the non-discrimination provisions of this contract, the
contracting agency shall impose such contract sanctions as it or the USDOT may determine to be appropriate,
including, but not limited to:
* With holding payments to the contractor under the contract until the contractor complies, and/or;
* Cancellation, termination, or suspension of the contract, in whole or in part