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STATE OF NEW MEXICO

FOOD SERVICE MANAGEMENT COMPANY (FSMC)

APPLICATION FOR REGISTRATION

SCHOOL YEAR 2016-2017

No FSMC bid for school food service in New Mexico can be considered by an SFA unless the FSMC has completed and filed this registration form with the New Mexico Public Education Department’s (PED) Student Nutrition Bureau (SNB). The form must be kept up to date with any changes. Please use additional pages where necessary to respond fully to each question.
Date FSMC submitted this registration to PED’s SNB:

COMPANY IDENTIFICATION

1. Company legal name and address (street, city, state and zip code)

Is the company a minority-owned enterprise? Yes No

2. FSMC Contact Information

FSMC Name:
Contact Person (s):
Mailing Address:
Telephone Number:
Fax Number:
E-Mail:

CORPORATE PROFILE

3. Is the company incorporated? Yes No

If yes, list what month, year and state in which FSMC was incorporated.

Month / Year / State

4. Does the company pay taxes in New Mexico? Yes No

If yes, what type (i.e. income, sales, etc.)

5. List other names the company is presently using or has used in the past twenty-four (24) months.

6. Is the FSMC currently providing or has the FSMC ever provided meals to the following programs (in New Mexico or other states)?

National School Lunch Program / Yes No
Number of National School Lunch Programs
School Breakfast Program / Yes No
Number of School Breakfast Programs
Summer Food Service Programs / Yes No
Number of Summer Programs

If yes, and if in New Mexico, complete the next section. Use additional pages if needed.

Program / SFA or Sponsor Name / Address / Phone

PERSONNEL PROFILE

7. List name and title of individuals from the company authorized to sign contracts.

Printed Name / Title

8. List all individuals who are owners, officers, local area representatives, consultants and any other persons with a 5 percent or more financial interest in the FSMC, and provide the following information for each:

Name / Officer/Title

ADDITIONAL INFORMATION

The following information will be used by the School Food Authority (SFA) when soliciting bids.

9. The company is currently providing service to SFA(s) in the following counties (check all that apply):

Bernalillo / Hidalgo / San Juan
Catron / Lea / San Miguel
Chaves / Lincoln / Santa Fe
Cibola / Los Alamos / Sierra
Colfax / Luna / Socorro
Curry / McKinley / Taos
De Baca / Mora / Torrance
Doña Ana / Otero / Union
Eddy / Quay / Valencia
Grant / Rio Arriba
Guadalupe / Roosevelt
Harding / Sandoval

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10. List the names of SFA(s) in New Mexico that have current Food Service Management Contracts with the FSMC but DO NOT participate in the National School Lunch Program (Attach additional pages, if needed).

School Food Authority Name / County

*Please attach a list if needed.

11. The FSMC will consider submitting proposals/bids to SFA(s) in the following counties for school year 2014-15 (check all that apply):

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12. List the minimum conditions that must generally be met on a county by county basis (i.e. minimum revenue, minimum number of meals/day, minimum number of schools, etc.) in order for the company to consider submitting a proposal/bid to the SFA: (Add pages if needed)

County / Conditions

13. List the names of all SFA(s) in New Mexico that had consulting contracts with the FSMC in the last two years:

Year / Local Education Agency / County

ASSURANCES

If selected as the FSMC by an SFA, this FSMC makes assurances as follows, which are incorporated by reference in each FSMC response to a request for proposals or invitation for bid and incorporated by reference in each contract for food services in New Mexico, including contract renewals. The initials of the signatory on each assurance below indicates acceptance of each provision by the person authorized to sign contracts:

A. ENERGY EFFICIENCY. The FSMC now complies and will continue to comply with the mandatory standards and policies relating to energy efficiency that are contained in the state energy conservation plan issued in compliance with the Energy Policy and Conservation Act (P.L. 94-163, 89 Stat. 871.) ___ (initials)

B. EMPLOYMENT HOURS AND SAFETY. The FSMC now complies and will continue to comply with Sections 103 and 107 of the Contract Work Hours and Safety Standards Act (the Act), 40 U.S.C. §327-330, as supplemented by Department of Labor regulations, 29 CFR Chapter 5. Under Section 103 of the Act, the FSMC shall be required to compute the wages of every laborer on the basis of a standard workday of eight hours and a standard workweek of 40 hours. Work in excess of the standard workday or standard workweek is permissible provided that the worker is compensated at a rate of not less than 1 1/2 times the basic rate of pay for all hours worked in excess of eight hours in any calendar day or 40 hours in any workweek. ___ (initials)

C. EQUAL EMPLOYMENT. The FSMC now complies and will continue to comply with, Executive Order 11375 entitled Equal Employment Opportunity, and as supplemented in Department of Labor regulations 41 CFR Chapter 60. ___ (initials)

D. CIVIL RIGHTS. The FSMC now complies and will continue to comply with the following civil rights laws, as amended: Title VI of the Civil Rights Act of 1964; Title IX of the Education Amendments of 1972; Section 504 of the Rehabilitation Act of 1973; the Age Discrimination Act of 1975; Title 7 CFR Parts 15, 15a, and 15b; the Americans With Disabilities Act; and FNS Instruction 113-1, Civil Rights Compliance and Enforcement Programs; Nutrition Programs and Activities. The FSMC agrees that compliance with this civil rights assurance constitutes a condition of continued receipt of federal financial assistance and that it is binding upon the FSMC and its successors, transferees and assignees for the period during which such assistance is provided.

_____ (initials)

E. BUY AMERICAN. The FSMC now complies and will continue to comply with the Buy American provision for contracts that involve the purchase of food, USDA Regulation 7 CFR Part 250.23. ___ (initials)

F. DEBARMENT AND SUSPENSION (E.O.s 12549 and 12689). This FSMC complies with and will continue to comply with debarment and suspension regulations at 7 CFR 3017. It hereby certifies that it has not been and its principal employees have not been parties listed on the General Services Administration's List of Parties Excluded from Federal Procurement or Nonprocurement Programs in accordance with E.O.s 12549 and 12689, “Debarment and Suspension.” It also certifies that it is not and its principal employees are not now on such list and have not otherwise been declared ineligible or otherwise excluded by statutory or regulatory authority other than E.O. 12549. ___ (initials)

G. CLEAN AIR AND WATER. The FSMC now complies and will continue to comply with all applicable standards, orders, or requirements issued under Section 306 of the Clean Air Act (42 U.S.C. 1857(h), Section 508 of the Clean Water Act (33 U.S.C. 1368), Executive Order 11738, and Environmental Protection Agency (EPA) regulations.

___ (initials)

H. CONSEQUENCES OF NONCOMPLIANCE. The FSMC certifies that it complies and will continue to comply with all applicable requirements of all state statutes, federal laws, executive orders, regulations, policies, and award conditions governing provision of school meal and snack services. The FSMC understands and agrees that if it materially fails to comply with the terms and conditions of the grant award, the New Mexico Public Education Department Student Nutrition Bureau may withhold funds otherwise due until the FSMC comes into compliance or the matter has been adjudicated and the amount disallowed has been recaptured (forfeited). The PED may withhold up to 100 percent of any payment based on a monitoring finding, audit finding or pending final report. __ (initials)

I. BACKGROUND CHECK. The FSMC shall ensure that the SFA has the information it needs to perform a security background check on any FSMC employee working at a school or, if required to do so, will conduct the security background check at its own expense.

___ (initials)

CERTIFICATIONS

The FSMC has signed the Certification of Independent Price Determination, Attachment A, which is incorporated herein by reference as an addendum to any New Mexico school food service bid/proposal and which is incorporated and made part of any New Mexico school food service contract awarded. ___ (initials)

The FSMC has signed the Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion, Attachment B, which is incorporated herein by reference as an addendum to any New Mexico school food service bid/proposal and which is incorporated and made part of any New Mexico school food service contract awarded. (Reference 2 CFR §417.) ___ (initials)

The FSMC has signed the Lobbying Certification, Attachment C, which is incorporated herein by reference as an addendum to any New Mexico school food service bid/proposal and which is incorporated and made part of any New Mexico school food service contract awarded. If applicable, the FSMC has also completed and submitted Standard Form-LLL, Disclosure Form to Report Lobbying (Attachment D), or will complete and submit as required. ___ (initials)

The undersigned certifies, to the best of his or her knowledge and belief, that:

1. No federal appropriated funds have been paid or will be paid by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of a federal contract, the making of a federal grant, the making of a federal loan, the entering into a cooperative agreement, and the extension, continuation, renewal, amendment, or modification of a federal contract, grant, loan, or cooperative agreement.

___ (initials)

2. If any funds other than federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this federal grant or cooperative agreement, the undersigned shall complete and submit Standard Form LLL, Disclosure Form to Report Lobbying, in accordance with its instructions. ___ (initials)

3. The undersigned shall require that the language of this certification be included in the award documents for all covered sub-awards exceeding $100,000 in federal funds at all appropriate tiers and that all sub-recipients shall certify and disclose accordingly. ___ (initials)

I CERTIFY that the information supplied on this application is true, complete and correct to the best of my knowledge. In addition, I certify that I am the person authorized to act on behalf of the FSMC in registration with the State of New Mexico and to execute contracts with any New Mexico School Food Authority. If I am not the person authorized, I am the person authorized to sign in that person’s absence. Any false statement or misrepresentation may be punishable by law (18 U.S.C. 1001).

Name of FSMC Official submitting registration documents:

Print Name:
Title:
Signature:
Date:

Name of person to notify if registration documents are incomplete or incorrect:

Print Name:
Title:
Phone number:
Fax number:
E-Mail:

ATTACHMENT A

INDEPENDENT PRICE DETERMINATION CERTIFICATE

I certify that, by signing this certificate in the New Mexico FSMC registration process:

1. / I am the person in this FSMC’s organization responsible within the organization for the decision as to the prices being offered in a New Mexico school meals proposal and I certify that this FSMC has not participated and will not participate in any action(1) restricting competition for provision of New Mexico school meals; (2) disclosure of prices quoted in a New Mexico school meals RFP or contract; or (3) inducement of any person or firm to restrict competition for providing New Mexico school meals.

2. / I am not the person in this FSMC’s organization responsible for the decision as to the prices being offered in an RFP and/or contract for New Mexico school meals. However, I have been authorized in writing to act as agent for the persons responsible for such decision to certify that this FSMC has not participated and will not participate in any action (1) restricting competition for provision of New Mexico school meals; (2) disclosure of prices quoted in a New Mexico school meals RFP or contract; or (3) inducement of any person or firm to restrict competition for providing New Mexico school meals.
To the best of my knowledge, this FSMC, its affiliates, subsidiaries, officers, directors, and employees are not currently under investigation by any government agency and have not in the last three years been convicted of or found liable for any act prohibited by state or federal law in any jurisdiction, involving conspiracy or collusion with respect to bidding on any public contract, except as follows:
Authorized Representative, FSMC / Title / Date

ATTACHMENT B