FORM A: supplier information
This Form A is required. See HISD Policy CHE (Local).
legal name of supplier: ______
data universal numbering system (duns) number: ______
type of business/description of products and/or services provided:______
______
______
supplier mailing address: ______
city: ______ state: ______zip code: ______
supplier street address: ______
city: ______state: ______zip code: ______
telephone: ______fax: ______
contact person’s name: ______
contact person’s telephone number: ______fax: ______
contact person’s e-mail address: ______
1. type of business entity: ☐ publicly traded corporation ☐ private corporation ☐ limited partnership
☐ partnership ☐ sole proprietorship ☐ not for profit entity
2. number of full time employees: ______number of part time employees: ______
3. is supplier is a resident bidder? ☐ yes ☐ no
a resident bidder refers to a person whose principal place of business in the state of texas,
Including a supplier whose ultimate parent company or majority owner has its principal place of
business in this state.
4. city and state of supplier's principal place of business: ______
if not Texas, does the state have preferential treatment on bids? ☐ yes ☐ no
if yes, what percentage: ______%
5. number of years supplier has been in continuous operation:______
6. number of years supplier has been in business under its present business name: ______
7. has supplier conducted business with the district under another name? ☐ yes ☐ no
If yes, provide other name(s):______
______
8. number of years doing business with hisd: ______
9. does supplier have a parent company or subsidiary that currently conducts or that has previously
conducted business with the district? ☐ yes ☐ no
If yes, name of parent company and/or subsidiary: ______
______
10. do you have experience with other school districts? ☐ yes ☐ no
if yes, names of school districts______
______
11. does supplier have any owners, principal shareholders or stockholders, officers, agents, salespeople or key employees who have been members of the hisd board of education during the last 5 years? ☐ yes ☐ no
If yes, name(s) and title(s): ______
12. does any officer, partner, owner, sales representative and/or spouse work for hisd? ☐ yes ☐ no
13. does supplier have any owners, principal shareholders or stockholders, officers, agents, salespeople or key employees who are district employees or who are members of a district employee’s immediate family who either work or who may potentially work on this contract with the district? ☐ yes ☐ no
If yes, name(s) and title(s): ______
______
14. names of authorized agents, including any person or entity authorized to ‘act with’ or ‘act on your behalf,’ such as consultants, sub-contractors, re-sellers, lobbyists, confidants, etc., whether compensated or not compensated:
______
______
______
______
15. does supplier have relationship(s) with any political action committees? ☐ yes ☐ no
if yes, name(s) of pac(s)______
16. has supplier (including any owner, principal shareholder or stockholder, officer, agent, salesperson, or employee) been involved in past, pending, or present litigation involving the District? ☐ yes ☐ no
if yes, please provide the style and status of the case as well as the type of litigation: ______
______
17. financial and business references, including bank with which supplier conducts business:
name of bank with which supplier conducts business: ______
_
bank officer: ______officer’s phone number: ______
name of other banking/financial institution(s): ______
______
18. name of insurance companies:
insurance companies / insurance companies19. hisd encourages the participation of minority and women owned businesses. Is supplier a minority and/or woman owned company? ☐ yes ☐ no
if yes, what percentage of ownership is minority or woman owned ______%
20. check one of the following: ☐ supplier will provide goods and services with own work force
☐ supplier will purchase goods directly from the manufacturer or other supplier
21. hisd can only do business with equal opportunity employers.
do you advertise as an equal opportunity employer? ☐ yes ☐ no
do you have a written non-discriminatory policy of employment? ☐ yes ☐ no
has this policy been circulated throughout your organization? ☐ yes ☐ no
person to contact regarding equal opportunity information issues:
name: ______title: ______
-----QUESTIONS REGARDING PROCUREMENT E-COMMERCE SOLUTIONS----
more information regarding the following questions and hisd’s e-procurement system may be found on part II, section 2.7 of this solicitation. (If section 2.7 in part ii is not applicable to this rfp, REMOVE QUESTIONS 22 TO 28)
22. name of contact person regarding it issues in your company: ______
23. is supplier participating in the optional e-commerce method described in part II, section 2.7 of this rfp? ☐ yes ☐ no
24. can supplier provide hisd with periodic preformatted flat file updates of your catalog? ☐ yes ☐ no
25. does supplier have e-commerce capability? ☐ yes ☐ no
26. does supplier have punch-out catalogs in place today? ☐ yes ☐ no
27. does supplier have any internal electronic catalogs with any customers? ☐ yes ☐ no
28. is supplier capable of providing a dedicated website with your catalog with hisd’s pricing? ☐ yes ☐ no
if yes, can your website interface with sap public section 7.0 / ecc 6.0 open catalog interface (oci)
compliant? ☐ yes ☐ no
i attest that i have answered the questions regarding supplier information truthfully and to the best of my knowledge.
______
officer’s signature
______
printed name
______
title
FORM b: MWBE INSTRUCTIONS
INSERT MWBE INSTRUCTIONS
Please refer to Attachment B-MWBE Participation Report that is located on HISD’s Procurement Web Site.
FORM C: REFERENCE SURVEY INSTRUCTIONS
Proposer must complete and return Form C as part of this RFP.
The Evaluation Committee considers Proposer’s reputation and reputation of Proposer’s goods or services in its evaluation of this Proposal.
Proposer to complete FORM C
The District requests the proposer to send FORM D (Proposer Reference) to their respected Clients for the purpose of their Client to complete.
The proposer’s Client is then to send the completed FORM D to (Sourcing Specialist), no later than the proposal due date of January 25, 2018 at 2:00pm CST
Please provide the name and contact information of all references to whom Proposer intends to send the FORM D (References).
Please provide the name and contact information of all references to whom Proposer intends to send the Survey.
(1) ______
Name of Entity or Business Contact Name
______
Email Address Mailing Address
______
Phone Number Goods and/or services provided
(2) ______
Name of Entity or Business Contact Name
______
Email Address Mailing Address
______
Phone Number Goods and/or services provided
(3) ______
Name of Entity or Business Contact Name
______
Email Address Mailing Address
______
Phone Number Goods and/or services provided
FORM D: REFERENCE SURVEY
To Whom It May Concern:
HISD is requesting the company completing this reference request, to send directly to HISD via email to on or before January 25, 2018 at 2:00pm CST.
NO. / CRITERIA / UNIT / SCORE1 / Ability to Manage Cost / (1-10)
2 / Quality of Product(s) and/or Services / (1-10)
3 / Quality of Customer Service / (1-10)
4 / Quick Response Time / (1-10)
5 / Ability to Maintain Confidentiality / (1-10)
6 / Close Out Process (invoicing, no unexpected fees) / (1-10)
7 / Communication / (1-10)
8 / Ability to Follow Rules, Regulations, and Requirements / (1-10)
9 / Overall Customer Satisfaction Based on Performance (comfort level using company again) / (1-10)
10 / Safety / (1-10)
TOTAL POINTS (out of 100) : _______
(I) How long have you done business with the Supplier? ______
FORM E: General CERTIFICATION FORMS
CERTIFICATION OF CODE OF SILENCE
The Board of Education (Board) has adopted a “Code of Silence” policy (Board Policy CAA (Local)) attached by URL link hereto and incorporated by reference.
The “Code of Silence" prohibits any communication regarding any RFP, bid, or other competitive solicitation between:
· Any person who seeks an award from the District or its affiliated entities (including, but not limited to, the HISD Foundation and the HISD Public Facility Corporation), including a potential supplier or supplier's representative, and
· Board members, the Superintendent of Schools, senior staff members, principals, department heads, directors, managers, or other District representatives who have influence in the evaluation or selection process.
The “Code of Silence” time period shall begin when the RFP is issued and ends upon the execution of the Contract. During the “Code of Silence,” campaign contributions, gifts, donations, loans, and any other items of value are prohibited between these parties, including candidates who have filed for election to the Board.
I hereby certify that I have reviewed Board Policy CAA (Local) pertaining to the “Code of Silence,” I and agree and understand that non-compliance with the “Code of Silence” policy may result in disqualification.
______Initials of Authorized Representative of Supplier
CERTIFICATION OF COMPLIANCE WITH TEXAS FAMILY CODE PROVISION
As per Section 14.52 of the Texas Family Code, added by S.B. 84, Acts, 73rd Legislature, R.S. (1993), all bidders must complete and submit with the bid the following: I, the undersigned Supplier, do hereby acknowledge that NO sole proprietor, partner, majority shareholder of a corporation, or an owner of 10% or more of another business entity is 30 days or more delinquent in paying child support under a court order or a written repayment agreement. I understand that under this provision, a sole proprietorship, partnership, corporation or other entity in which a sole proprietor, partner, majority shareholder or a corporation, or an owner of 10% or more of another entity is 30 days or more delinquent in paying child support under a court order or a written repayment agreement is NOT eligible to bid or receive a state contract.
______Initials of Authorized Representative of Supplier
CERTIFICATION OF AUTHORIZATION, PERMITS, AND BUSINESS CERTIFICATES REQUIREMENT
For the duration of the Contract, Supplier must have and maintain current licenses, permits, fees, business certificates and similar authorizations required by the City of Houston, Harris Country, and the State of Texas to conduct business and provide awarded goods and/or services to the District. Upon the request of the District, Supplier shall provide copies of all licenses, business certificates permits and fees as being paid and current that are required to do business by the city, county and State for the type of business Supplier provides, or seeks to provide, to the District.
Supplier understands and agrees to abide by the Authorization, Permits, and Business Certificates Requirement above. Supplier certifies that it has all current licenses, certificates, similar authorizations required by the City of Houston, Harris County, and the State of Texas to conduct business and/or provide awarded goods and/or services to the District.
______Initials of Authorized Representative of Supplier
CERTIFICATION OF ANTITRUST CERTIFICATION STATEMENT –Texas Government Code Section 2155.005
My initials below affirms under penalty of perjury of the laws of the State of Texas that:
1. I am duly authorized to execute this Proposal/Contract on my own behalf or on behalf of the company, corporation, firm, partnership or individual (Supplier) listed below;
2. In connection with this proposal, neither I nor any representative of Supplier have violated any provision of the Texas Free Enterprise and Antitrust Act, Tex. Bus & Comm. Code Chapter 15;
3. In connection with this bid, neither I nor any representative of the Supplier have violated any federal antitrust law; and
4. Neither I nor any representative of Supplier have directly or indirectly communicated any of the contents of this proposal to a competitor of Supplier or any other company, corporation, firm, partnership or individual engaged in the same line of business as Supplier.
______Initials of Authorized Representative of Supplier
CERTIFICATION REGARDING HAZARD ANALYSIS AND CRITICAL CONTROL POINTS (HACCP)
All products purchased by HISD must be manufactured in compliance with HACCP regulations. Supplier certifies that: all products on this proposal are processed and packaged in a HACCP compliant plant. Supplier agrees Supplier further understands that HISD requires processors to maintain records and monitoring logs pertaining to HACCP compliance, at a minimum, in the following Key Areas of HACCP compliance:
· Hazard Analysis
· Critical Control Points established and limits set
· Planned procedures in place to correct processes when deviation may occur
· Detailed and accurate record keeping
· Verification procedures
· Equipment installation and maintenance
· Master cleaning and sanitation schedule
· Orientation for all employees
· Ongoing training on food safety and HACCP procedures
· Separation of food and chemical products
· Refrigerated dock receiving and loading
· Master cleaning and sanitation schedule
· Time/Temperature monitoring
· Pest Control
Supplier further understands and agrees that documentation and monitoring logs must be verified by an acceptable third party auditing firm or government agency and provided to HISD upon request. Supplier also understands and agrees that if a processor loses inspection/processing rights or has a recall involving product sold to HISD, Supplier must notify HISD within 24-48 hours.
______Initials of Authorized Representative of Supplier
CERTIFICATION OF SUPPLIER (AND IF APPLICABLE, SUBCONTRACTOR)
NATIONWIDE CRIMINAL BACKGROUND CHECKS
Pursuant to sections 22.085 and 22.0834 of the Texas Education Code Sections 22.085 and 22.0834 and HISD Policy CJA (Legal), Supplier hereby certifies that all of Supplier’s employees, subcontractors and volunteers (including those hired before January 1, 2008) who have, or will have, continuing duties related to the contracted services, and who have, or will have, direct contact with students, have passed a national criminal history background record information review as required by those sections and by HISD Policy CJA (Legal). Supplier understands that if an employee subcontractor, or volunteer has a Disqualifying Criminal History, the District may elect not to enter into this Contract or may elect to cancel the Contract.