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i¿i¿~/¿vv~ i~. vv tAA ~v i~~~ IVti I lil\vt.KJ.i;r. 12/19/2005 12:56 FAX 2015416579 8UIl\DINaBISTRI:l: 11M irt i l;rt imUI~/Vltl lI ,ii' 1 ".. I. INSTRUCTIONS FOR COMPLET NG THE EMPLOYEE IN FORMATION Rl:PORT FORM AA302) JMPORTANT: . . READ THE FOLLOWING INSTl~UCTlONS CAREFUI.I. Y Ð FORE COMPLETING THE r:ORM. PRINT OR 1YPC: ALL INFORMATION. FAILURe TO PROPERLY COMPLET THE ENIRE FORM MAY OSI.A'f ISSUANce OF YOUR ceRTIFICATE IF YOU HAVE! A CVR!NTCE;RilFICATS or ØflPI.OYëE INFORMATION REPORT,lbO NOT COM~i.E: E THIS FORM. SEND COPY OF CURR~Ni CERTIFICATE TO THE P.UBUC AGENCY. DO OT OOMPLET.E THIS FORll1 FOR CONSTRUCTION CONTRACT AWARDS. .ITEM 1 - F.ntor the f'odi:rú lcantlßoatlci NUl1bCir anslnnlJr, I))' 1M Intemol ROY8nUC Snl\'kn. or If ø r:l,doral Employ.,r IC:I1nliljøiit/øn Numllr 1\Ø1. h~n iipPIID4 rot. or ir your bui:lnu~D I' øuch tht yo hov not Or Wlh 1101 recew ø fodOr11 I:pIOYOl/danllti::titi Numbnr. lnltt tho Socleil SGcurity Numiir of thli OVinar ar Dr on" parnot. Ii\ Ihl! CGlI of ø piulner.hlp . ITEM 2. Chcr li bo :i~proixale to your 'I'PE OF DualN EUS. If)'l 01' enuaSlnd In moio lhi;n ono tyo cif hunlnip checIClIo pmdC''l1nClto oric, II you oro .. m::\lll.c\urf dorlngmClra than tsO% of your l~cDJplii frni your cwn rCltall oinob, ëh 9ck -.RlitaJl'ò ITeM S .liricer ih lolAl'rUlnbál" 0' omployoa In IIi entiA! 1".ulilpany.lncldl pa-liina cmployull. ""i~ nl'inbcir MAtt InclurJu all fAcJlllqa In 1lo ~nt1r-. flrl1 or r.i,oriillan. ITEM," . (':1110r th9 nM'8 :,y whltii Uia compiny Is IdanOßotl If U:cro ii mora ih ono c:omp:my nanlO, cntt!ilhe procfomlniite ono. . ITEM tJ - E!ntl!t dIG pnY$IC:311C1a:lion cd itl; ~/'l'y. InclUde CIty, County. $llo and ZIJ) Codu. ITEM G . I:,;tet lha niimei' any puront or alllll1llJ company Inciuding 11'8 Cit, County. siale and Z1~ Code. If tho iø IIOIlg. 110 Indcoto by onlltilng .NÐno~ or NlA. ITEM 7 -Chock 1111 bo)C ClpPprl~to to your typo 01 COI1PQI')' eslabtlshmonL .Slilo-tabllølienC Empløyol" shall Indudo. lin omploYEt y,l()G bualn.2Do 10 condUcted Ðt only orio phyøfci:l locallan i.u1tJ$tallhmøni Eniplo)'(' shall Indldo Pr1 employr Wll':,o bU&IMS~ Is conducld a' mON' Ihti anD IClCDlIn. llEM 8 .Ir "MUII.88lllDJliihmoni" we. øntlil' 11' Ilem Ð. f1nlnr tho num!?or ololtab\hl1lmtl Wlthln tho 8tute or lI(\w Jersoy. . ITeM 9 .. Enlor Ihe 10101 number of oipJoyeo~ at thO 4):tibllhI'IOrilbolnø øwar:fadlll$ CONtAct ITeM 10 w Enlotho name of tho PubloAgoricy IiWArclll,g thCl conuøcL fnduo Ci)', Coty. ~lRte and Zip Co~e. TYPE OR PJ\INTIN SHARP BAloL PO tTl\, 11 "t:nt r iho iippropi1alo f1qureR on all hnor¡ Rnc In all colur'I. nil SHALL ONI. Y INCLUDE EMPLOYMeNT DATA rn.OM lit: FACILIl Y '.HA T iS BEING I\WARDEU THE CON li CT. 00 NO" lI:1t Ih IIIJ omplayoo In mOnt Uian ono Job ~l"Dor. DO NOT Oliui, an ev.C)1 Report. . R:lQJlUSthnl Groups win bo defli'od; Diiiok: Nui.al l,pAlile gtlgln. Pør:iQl0 hGvli'll c:tloln In Bny 01 Iho Btncl nid I grouJ'1l of ,A.frlca Hlllpanlc;: Po llOnA of MGXI"'''''. P\orto Rloo, Cuban. or ClJl1lralor Sa Ut Arli~llcõ2n or olhnrSpanlSh culturo or orloln. roøIUIIC1l1" of 8CQ . Amorlclllln Ian ørAI~'GI(.n NAt/VO: poraoni h&'Vinn oilalri:; iii any at Ut itllial p~'Opla:a ::f NOt\h MtU"=' anc who ma1ntnln cilh rilldenitnootlon through lral arriUllticin nr c:mmunll) iuon. Alllnn 0" Pao tic l:aliiider: f1"rIQO~ tinvJra orialn In Rnv nr 'he orllngl opki:o 01 U10 r'ar rb So~ltho:GtAGilt. th:i Indloo Sult.c nl,""n' ot dWi f'uciOc InlanCls. TI\16 cirOQ InclucQ3 for :ipl", China. Japan.l(. the Phillpplnl1 laloml. and Qftn4. Noii.flnad : Nt I'artian: not Idlil\llIad In:iny 0' lhet li(0oiltunU R(ld:JIJIhIIG Groupe. ITl., 12 . C eck U1(' AIJPropriaie bOle II the race or ethnl . uraup Inrm Uon WO!' ~Q1 obtDlnod ii 1 or 2. Ri'ecil) by what otht means Ill WÕS done In 3. . ITEM 13 . r. r thii d:ilg!l of chit piioD parfod iiicr! to pr.ipMo (ho ' ploymon\ dabs proionled In tlom 12. 'Yo,". . IT5M 14.1f hlt It thea f1rn\ Urre .nEinplOyQ Infori;iUc Report hui: submitted far thin c:mpany. chock bloc ITEM 16 -If he anawt tn I'om 15 Ì$ "No., ~ the data when th Ji Iimployee lnronnl2lan RopOlt wan DUbmlt by this cop~." . ITEM 1 0 . P nt or ty U'l nalCl of Iho peiMn completll1 ih fOr, In ucl tho a'gnaturv, IIUC en dat. IT1M , T . E lor 110 PhYDlcal'loc:itlri IIOl' the form Is boll\ø cipJclad, .1 lude eii" Slate. ZI COdo and Phane Numbar, 'IHli VßNDOIUS 10 COMi'ura 1HEMl'L()Yrii JN1ioRMi\ nON moaT f"Olt (A303) AND RBTAIW COPY FOJl111R V~l,OJ~'S OWN JlfLt!S. .;116 VEDOR. IS l'U !l"tJDMI'r A COpy TO nm PU9UC OSNCY AWARD1NO nIl CONTJCT AND :Fan-WAItO A COI'Y Tn NJ Pepin11oat of.thTrn'l Ðfveiloii ofColitncl Complliini:e & teClIIRIBIlJlO iient Oiiii,,"qnlty '.' P,o. Jox,Z09 'llGn, Nqw JatUay al.i~2.08 : Tal phono No. (108) =11.8478 I
--- I~I'~/LYV~ ~~.yy Iftft 'V'~~~IVOI ~i1\, r:n.."", IfY .'1, V 10
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City Clerk File No. Agenda No. Appr
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Continuation of Resolution City Cle
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()- 00;1 EXHIBIT A JAN i 3 2010 BLO
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Block: 00763 Principal: 3,167.01 Ta
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N N N ~ -c N m 0 0 0 0 ;i 0 0 0 0 ;
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Memo to Brian O'Reiley, Business Ad
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Resolution of the City of Jersey Ci
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LEGISLATIVE FACT SHEET This summary
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of the Licensee or anyone employed
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14. Failure to adhere to the terms
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HOST CITY AGREEMENT THIS HOST CITY
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provided in writing by the Red Bull
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on the first business day following
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(1) Severabilty. If any provision o
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SCHEDULE A SERVICES The City shall
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.. November 16, 2009 Paragraph D -
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Aricle 26 November 16, 2009 Paragra
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Aricle 30 Insert New Paragraph H as
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Aricle 36 November 16,2009 Add new
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wil be $50 per 30-day supply, meani
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CERTIFICATION OF BRIAN O'REILLY IN
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. AFTI ACTION COMPLIACE NOTICE N.J.
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EXITA N.J.s.A. 10:5-31 aDd N.J.AC.
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APPENIX A AMRICANS WI DISABIL ACT O
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" Taxpayer Identifcation# 221~896.1
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0148637 CITY OF JERSEY CITY Requisi
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A summary of Aetna's proposal rates
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City of Jersey City Dental Program
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UL-\, .L C- C-UiiO .L-i- Jc: veL I
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CERTIFICATION OF BRIAN O'REILLY IN
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-,-~._'~_.,----_._.~.._--_.- -'-~--
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EXIT A N.J.s.A. 10:5-31 and N.J.AC.
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APPENDIX A AMRICANS WI DISABIL ACT
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-~_.._- ._----~_._-~.._----_._----~
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Reqúisition # 0148636 Vendor DELTA
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. A sumary of Aetna's proposal rate
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Total Annual: Total Monthly: $158,0
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VcL-l¿-¿~~~ IJ;J¿ DEL TA DENTAL
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EXTRAORDINARY UNSPECIFIABLE SERVICE
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Requisition # 0148639 Vendor RELIAS
Page 95 and 96: EXIT A N.J.s.A.IG:5-3la.d N.J.A.C.
Page 97 and 98: APPENIX A AMRICANS WI DISABIL ACT O
Page 99 and 100: ./ Resolution of the City of Jersey
Page 101 and 102: Resolution of the City of Jersey Ci
Page 103 and 104: FULL TITLE OF RESOLUTION: RESOLUTIO
Page 105 and 106: 61/64/2636 12: 62 9735860221 JAALE.
Page 107 and 108: 01/04/2030 12: 02 9736800221 JAALEX
Page 109 and 110: Continuation of Resolution City Cle
Page 111 and 112: . ..... ~_.... .., CITY OF JERSEY C
Page 113 and 114: 12/16/2009 18: ~1 9732435549 PAG 02
Page 115 and 116: : 12/1&/2009 17: 56 , ILl 19"'1111"
Page 117 and 118: .. .. I\ .. ., . (7 .. I\ lS lS iD
Page 119 and 120: i.~l.s't~ee~ .!?:S~ .... ~Z~~~~ss~~
Page 125 and 126: : ::. _._'.- ::-: - - CERTiF1CA l"E
Page 127 and 128: '. c: ,,. -l r- '#e... - - - ~ :J ,
Page 129 and 130: 12i'6/2E1E19 17: 56 9732435549 IL/1
Page 131 and 132: 12/16/2009 18: 41 9732435549 PAGE 0
Page 133 and 134: 12/1&/2009 18: 41 9732435549 PAGE 6
Page 135 and 136: i.~rl.~(~ElElê l!3: ~1. '" ~H~~4~S
Page 137 and 138: ":.'~" (l-~.. DEPAATUE1' OF 1'REASY
Page 139 and 140: I~/~~/~UU~ I~:O~ t~A ~UI~~~IUHl 12/
Page 141 and 142: I~/~~/~UU~ ,~.~~ rftA ¿U'~~~IUbl 1
Page 143: I~/~~/~UU~ I~:U~ tAA ~UI~a~IUijl lo
Page 147 and 148: i",~"yy~ 1~.YI rftn ~UI~~UIUbl IdAV
Page 149 and 150: EXHIT A 'MAATORY.EQUAL EMPLOYM OPPO
Page 151 and 152: C6r~ôn CERTIFICATE OF EMPLOYEE INF
Page 153 and 154: MioritylWoman BuSÎJess Enterprise
Page 155 and 156: .: i ..; ..' . TAXPAYER NAME: CHUKS
Page 159 and 160: AGREEMENT AGREEMENT made this _ day
Page 161 and 162: ARTICLE iv Compensation and Payment
Page 163 and 164: loss of life or property or in any
Page 165 and 166: executed by their duly authorized o
Page 167 and 168: EXBmIT A (Cant.) The contractor or
Page 169 and 170: Questionnaire for Bidders Jersey Ci
Page 171 and 172: City Clerk File No. Agenda No. Appr
Page 173 and 174: " Treasurer ~: State Certification
Page 177 and 178: ,"" -' CERTIFICATION IN SUPPORT OF
Page 179 and 180: Consulting Services Agreement For t
Page 181 and 182: A. The selected consultant shall pu
Page 183 and 184: The parties hereto reserve the righ
Page 185 and 186: A business organization that fails
Page 187 and 188: ~ ~ '~ 10 * D . It ~ . D ~ I, j .,'
Page 189 and 190: ~" ~".: J : . . .: 'f ", J i ~ ,- ~
Page 191 and 192: , " .I~""IUI lt'~ IA I: (r¡1"~ 53t
Page 193 and 194: t '. " l ~. ~ON CO~LrlMON ~A~ STATE
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! . ¡', '" I.: " l~ . CERnFCATION
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This Agreei:ent dated the AGREEMENT
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approved in advance for any specifi
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et seq. 2. An Affirmative Action Em
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iLliiIL~~~ lL:LL Lin -~4 1-~23Ø LA
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...... oJ, r ...£~U LAW DEPT PAGE
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Page') of2 00491S4 II ,....... 8QVA
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12/11/2009 12:22 201-547-5230 LAW D
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LL(iiIL~~~ l¿:¿¿ :¿1:1-54 7 -52
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1¿/li/2ElEl9 12:22 201-547-52313 L
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City Clerk File No. Pg. #-- Agenda
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~i/~ii~~i~ 'l~:~~ ~~1-541-523Ø . .
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. ; ii/12/20El9 10: ld 2131-547-523
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U~'ur(~u¿u ¿~~~~ L~i-~q(-~~~~ 11/
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JRN-07-211111 15:34 trDm:2016536979
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month an affidavit of services spec
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The City does not agree to pay for
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administration of this contract. Al
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such as court reporters, investigat
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The City does not agree to pay for
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12(lS!20B9 11:52. 281-547-5230 lA D
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i~/l~/2BB~ 11: 52 08nll7t'''9 11:90
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12/1B/20e9 11: 52 OI/~.I;OOB t1'~1
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12/18/2e09 11: 52 ~l/~4/~OØ9 '1;31
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12/18/2e~9 11~52 291-547-5238 LAW D
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12/19/2Ð09 11: 52 2ßl-547-5230 I.
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12/1ß/ze09 11 :52 201-547-5230 LA
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- ... '.'.. . . + 12/iB/28Ðti 11:5
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12/iS/2ee9 11: 52 281-547-5230 LAW
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AGREEMENT . Ths Agreement dated the
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Should the services of one or more
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affixed the day, month and year abo
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Continuation of Resolution Pg. # 2
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cents ($1.50) per page; and (ii) ch
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pursuant to section 1 ofP.L.2001, c
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l:1/l:4/2E:l: 12: 10 201-547-5230 L
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~i/04/2010 12: 10 12/3ß/zÐÐ9 iø
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01/64/2610 J.:O ,jt;l :'I:ll:l': 12
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." ~l/~q/~~lØ l2~10 1~/3e/2009 18:
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~1/tlq/2~1~ 12: 113 12/36/2e~9 i~:
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~i,~q,~~i~ l~:l~ 2~1-547-5230 12/30
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~1/Ø4/2~1~ 12: 1~ 201-547-5230 i~i
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4""'& "".. r - .j'~U LHW Ui=r-, PAG
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.&¿.. .LV Lui -J"l t -;"L.::U:I -~
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~~, u~, ¿u¿u ¿¿~iD iLI ~~I ~~~~
Page 295 and 296:
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the preceding month. All statements
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complete or substantially complete
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Robert Byrne City Clerk Brian O'Rei
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Continuation of Resolution Pg. # Ci
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Requisition # 0148621 Vendor SOLOMO
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City of Jersey City Department of H
Page 309 and 310:
VII. RECORDS AND FILES' All patient
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EXHIBIT A (Cont.) The contractor or
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.. ". \ .~ . ..' '::' . . . .~ . ,~
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MINORITY/wOMAN BUSINESS ENTERPRISE
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-d!.~tlN~Ni~y "i"" State' Of New Je
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Princeton Insurance Company COMMON
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. BUSINESS ENTITY DISCLOSUR CERTIFI
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Requisition # 0148192 . Vendor EDUC
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EEO/ AFFIRMATIVE ACTION REQUIREMENT
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MINORITYIWOMAN BUSINESS ENTERPRISE
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P.L. 2004, c. 57 (N.J.S.A. 52:32-44
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, .' C. 271 POLITICAL CONTRIBUTION
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C. 271 POUTICAL CONTRIBUTION DISCLO
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List of Agencies with Elected Offic
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BUSINESS ENTITY DISCLOSURE CERTIFIC
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AGREEMENT THIS AGREEMENT entered in
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6. Purchases C) The City may send a
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12. Retention of Records Financial
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17. Labor Standards All laborers an
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Requisition # 0148794 Vendor HORIZO
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EEOIAFFIRMATIVE ACTION --REQUIREMEN
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State Treasurer HORIZON HEALTH CENT
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l'l.J. LlCIJWLllCHl VI llCè1:Sury
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C. 271 POLITICAL CONTRIBUTION DISCL
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Page_of Vendor Name: Continuation P
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CERTIFICATION OF COMPLIANCE WITH TH
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3. Compliance with Approved Program
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B) Subgrantees that receive at leas
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comply with such additional conditi
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20. Political Activity Prohibited N
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DETERMNATION OF VALUE CERTIFICATION
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EXHIBIT A MANDATORY EQUAL EMPLOYMEN
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APPENDIX A AMERICANS WITH DISABILIT
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Page L ot3 Public Contracts Equal E
Page 394 and 395:
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P.L. 2004, c. 57 (N.J.S.A. 52:32~44
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N.J. uepartent of Treasury - Uivisi
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Page_of Vendor Name: o Check here i
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DETERMINATION OF V ALUECERTIFICATIO
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EXHIBIT A MANDATORY EQUAL EMPLOYMEN
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APPENDIX A AMERICANS WITH DISABILIT
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P.L. 2004, c. 57 (N.J.S.A. 52:32-44
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C.271 POLITICAL CONTRIBUTION DISCLO
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. ~ , BUSINESS ENTITY DISCLOSURE CE
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AGREEMENT TIDS AGREEMENT entered in
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6. Purchses C) The City may send a
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ATTACHEMENT A PROGRAM DESCRIPTION:
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AGREEMENT . THIS AGREEMENT entered
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6. Purchses C) The City may send a
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ATTACHEMENT A PROGRAM DESCRIPTION:
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~. Requisition # 0148802 Vendor PHI
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EEO/ AFFIRMATIVE _.._----_._."---.
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Certification 778 CERTIFICATE OF EM
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MINORITYIWOMAN.BUSINESS ENTERPRISE
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l'l.J. UCPi:UIlCUl UL HCa:sury - Ui
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AGREEMENT THIS AGREEMENT entered in
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C) The City may send a representati
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Requisition # 0148804 Vendor . . PR
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EEO/ AFFIRMATIVE - --- - ----~- ---
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- --"- - - - -- - ----- - - - - - -
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n.J. Ui;paiulll;llt vi ill;~UlY - u
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Page ::of 2- Vendor Name: Continuat
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City Clerk File No. Pg.#~ Agenda No
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Date Submitted ORDINANCEIRSOLUTION
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'~""- " JON S. CORZINE Governor Dec
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WILLIAMR. GOBLE, P.E., CITY ENGINEE
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Grant Application for State Aid to
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Grant Application for State Aid to
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Scope of Work cant' d Grant Applica
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CITY OF JERSEY CITY o E PA R TM E N
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Engineer's Estimate (12.03-2009) IT
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Project Classification (J Pedestria
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Name of Grantee: Jersey City Organi
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;:t:dn udlldynt:.. - Un:in¡; "'t:~
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LEGISLATIVE FACT SHEET This summary
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10. Any equipment installed or used
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Cit Clerk File No. Agenda No. 10.Z.
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and fully cooperate with the Direct
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7. Plan for collection ofuutstandin
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Dated: ~ SHEET 1 Dated: Director of
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Sheet 2 RECORDED VOTE- Ayes: SO-rOL
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SHEET3A ,. SEE BUDGET APPROPRIATION
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SHEET3B_1 PRIORYEAR.'S LOCAL MUNICI
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SHEET3C Totals days 265,942 $73,979
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09-206 34,736,189 ________-:_____._
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SHEET 9 ----_....__...._------_.._-
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01/12/10 SHEET 15A _________.._____
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01/12/10 SHEET 18A I I I 13,711 I T
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I 01/12/10 SHEET 240 I I I I , ----
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TÖTALCAPITAL IMPROVEMENTS FROM "CA
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(Tis appendix must be Included in a
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Sheet 40b C-3 TOT ALS- ALL PROJECTS
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TOTALS. ALL PROJECTS 33-399 210,155
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Sheet 44 JAN 1 3 2010 Date If you h
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Year 2010 temporary budget to make available the ... - Jersey City

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