Transportation Services Bid Form

Bid Proposal Cover Page

Agency Organization Submitting Proposal

Name:______

Address:______

City/State/Zip Code:______

Check One:

Sole Proprietor

For-profit organization

Not-for-profit organization

Government organization

Proposal contact person______

Contact person’s telephone______

Federal Employee I.D. number, if applicable______

Workers Compensation Account number, if applicable______

Proposed amount of funds requested______

Included:

Budget

Qualification of staff

Documentation of Insurance

Narrative

______

Authorized SignatureDate

Typed Name and Job Title

Appendix 1

TRANSPORTATION SERVICES BID FORM

STANDARD (WALK ON) SERVICE

Flat Fee for Local Service$ ______

Long Distance Service (per mile)$ ______

Hourly rate for Work Participate

Projects (such as Work Experience site)$ ______

Waiting Fees (per hour)$ ______

(If Applicable)

Bid Submitted by:

Company Name

Company Representative Name and Title

Authorized Signature

Date

Appendix 2

TRANSPORTATION SERVICES BID FORM

MOBILITY AIDED (WHEELCHAIR, SCOOTER) SERVICE

Flat Fee for Local Service$ ______

Long Distance Service (per mile)$ ______

Hourly rate for Work Participate

Projects (such as Work Experience site)$ ______

Waiting Fees (per hour)$ ______

(If Applicable)

Bid Submitted by:

______

Company Name

______

Company Representative Name and Title

______

Authorized Signature

______

Date

Appendix 3

PERSONAL PROPERTY & REAL ESTATE TAX AFFIDAVIT

STATE OF OHIO }

}SS:

COUNTY OF MEDINA}

______being first duly sworn, deposes and says that he/she is

(president, secretary, sole owner, etc.) of: ______

______the party making the bid, with offices located at: ______and as its duly authorized representative states that effective this ______day of ______, 2015 (date of submission of the bid) the (Name of Company) ______

( ) Is NOT charged with delinquent personal property or real estate taxes on the general list of real and personal property in Medina County, Ohio, or any other counties containing property in the taxing districts under the jurisdiction of the Auditor of Medina County, Ohio.

( ) Is charged with delinquent personal property taxes and/or real estate taxes on the general list of real and personal property in Medina County, Ohio, or any other counties containing property in the taxing districts under the jurisdiction of the Auditor of Medina County, Ohio. The County and amount of delinquent personal property taxes is listed below and includes total amount and any penalties and interest thereon.

County:Amount:

______

Affiant

Sworn to and subscribed before me this ______day of ______, 2015.

______

Notary Public

Appendix 4

NON-COLLUSION AFFIDAVIT

STATE OF OHIO }

}SS:

COUNTY OF MEDINA}

______being first duly sworn, deposes and says that he/she is

______(president, secretary, sole owner, etc.) of: ______; the party submitting the foregoing bid; that such bid is genuine and not collusive or sham; that said bidder has not colluded, conspired, connived or agreed, directly or indirectly, with any bidder or person, to put in a sham bid, or that such other person shall refrain from bidding, and has not in any manner, directly or indirectly sought by agreement or collusion, or communication or conference, with any person, to fix the bid price of affiant or any other bidder, or fix any overhead, profit or cost element of said bid price, or that of any other bidder, or to secure any advantage against the County of Medina or any person or persons interested in the proposed contract; and that all statements contained in the bid proposal or bid are true; and further, that such bidder has not, directly or indirectly submitted this bid, or the contents thereof, or divulged information or data relative thereto to any association or to any member or agent thereof.

______

Affiant

Sworn to and subscribed before me this ______day of ______, 2015.

______

Notary Public

Appendix 5