CONTRACTORS AFFIDAVIT AND AGREEMENT
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 contracting with Liberty County School System, a political subdivision of the State of
Georgia, has registered with and is participating in a federal work authorization program*
[any of the electronic verification of work authorization programs operated by the United
States Department of Homeland Security or any equivalent federal work authorization
program operated by the United States Department of Homeland Security to verify ·
information of newly hired employees, pursuant to the Immigration Reform and Control
Act of 1986 (IRCA), P.L. 99-603, in accordance with the applicability provisions and
deadline established in O.C.G.A. § 13-10-91.]
See Employment EligibilityVerification (EEV) at
https:/lwww.visdhs.com/EmployerRegistration
The undersigned further agrees that, should it employ or contract with any subcontractor(s)
in connection with the physical performance of services pursuant to this contract with
Liberty County School System, contractor will secure from such subcontractor(s) similar
verification of compliance with O.C.G.A. §13-10-91 on the Subcontractor Affidavit
provided in Rule 300-10-01-.08 or a substantially similar form. (See Form 'C") Contractor
further agrees to maintain records of such compliance and provide a copy of each such
verification to the Liberty County School System at the time the subcontractor(s) is
retained to perform such service.
Employment Eligibility Verification Program
(EEV)Basic Pilot Program* User Identification Number
BY: Authorized Officer or Agent
(Contractor Name)
Title of Authorized Officer or Agent of Contractor
Printed Name of Authorized Officer or Agent
SUBSCRIBED AND SWORN
BEFORE ME ON THIS THE
_____ DAY _______,
2
20
0
Notary Public
My Commission Expires;_ _ _ _ _ _ _ _ _ _ _
•AsoftheeffectivedateofO.C.G.A.13-10-91,theapplicablefederal workauthorization programisthe"EEV/Basic
Pilot Program" operated by the U.S. Citizenship and Immigration Services Bureau of the U.S. Department of Homeland
Security, in conjunction with the Social Security Administration (SSA).
END OF FORM
FORM"R'
REFERENCE Contact Information
Please provide contact information for a minimum of three (3) references that can attest
to your job performance on projects similar in size and scope as the project being bid.
You may provide such additional information as you see fit
Name of Contact
Representing:
Phone Number(s) Description of Project (s) Referenced: name of project, date,
individual, firm or
scope and etc.
organization
FORM"D"
SEX OFFENDER ACKNOWLEDGEMENT FORM
Read, sign and return this form to the Liberty County Board of Education along with bid proposal
The Contractor (or Vendor) shall not knowingly send any employee, agent or subcontractor personnel who is a
registered sex offender or who has been convicted of sexual abuse to any school building or school property when
students are attending school or a school related activity.
The Contractor (or Vendor) shall make periodic criminal history record inquiries as authorized by O.C.G.A.
§35-3-34, as now written, or here-after amended; or allowed by all or any other laws allowing such inquiry, to
identify these persons who have been convicted of sexual abuse or any other act which would require such person
to be entered into a national or state sexual offender registry.
For the purpose of this policy, the term periodic shall mean that the criminal history record inquiries shall be made
current upon the awarding of a successful bid on contract and checked no less than annually during the duration of
the contract.
The Contractor (or Vendor) is certifying to the Liberty County Board of Education that periodic criminal history
record checks are made by the company for all employees and that to the best of the Contractor's (or Vendor)
knowledge it has no employee or agent who has been convicted of a sex offense or who is a registered sex offender,
who will be assigned to any school building or school property while students are attending school or a school
related activity.
I have read and understand the above Liberty County Board of Education Policy regarding me or my
company's obligation as a contractor (or vendor), I further acknowledge that the failure to comply with the
requirements to identify a sex offender, to comply with any part of this policy, to assign a sex offender to
any school building or school property while students are attending school or a school related activity will
constitute a breach of the contract.
Company Name--------------------------------
ContractorVendor Signature
Witness Signature
Date Signed
Date Signed