INVITATION TO BID - City of Champaign

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B. No department director or any employee or any officer of the City of Champaignhas any financial interest, directly or indirectly, in the award of this contractexcept as listed on a separate attached sheet to this affidavit.C. That the Contractor/Vendor is not barred from bidding on any contract, if bidding processwas used) as a result of violation of 720 ILCS 5/33E-3 and 5/33E-4 (Bid Rigging or BidRotating).SECTION 3. DRUG FREE WORKPLACE AND DELINQUENT ILLINOIS TAXESSTATEMENTThe undersigned states under oath that the Contractor/Vendor is in full compliance with theIllinois Drug Free Workplace Act, 30 ILCS 580/1. The undersigned also states under oath andcertifies that Contractor/Vendor is not delinquent in payment of any tax administered by theIllinois Department of Revenue except that the taxes for which liability for the taxes or the amountof the taxes are being contested, in accordance with the procedures established by theappropriate Revenue Act; or that the Vendor has entered into an agreement(s) with the IllinoisDepartment of Revenue for the payment of all taxes due and is in compliance with theagreement.SECTION 4. FAMILIARITY WITH LAWS STATEMENTThe undersigned, being duly sworn, hereby states that the Contractor/Vendor and its employeesare familiar with and will comply with all Federal, State and local laws applicable to the project,which may include, but is not limited to, the Prevailing Wage Act and the Davis-Bacon Act.CONTRACTOR/VENDOR______________________________________SignaturePrinted Name: __________________________Title:__________________________________SUBSCRIBED and SWORN to before me this ____ day of _______________, 20___.________________________________Notary PublicMy Commission Expires: _______________________Form D-6 01/09
Community Relations Office102 North Neil StreetChampaign, Illinois 61820(217) 403-8830 or (217) 403-8835 (fax)Requested by:Office Use OnlyDate:Approved by:Date:Vendor Number: Code: Entered: CROFINCertificate Number: Certificate Expiration Date:AFFIRMATIVE ACTION REPORT FORMFailure to properly complete and sign this form prior to the execution of a contract with the City, or within 7 daysafter a request to submit this report, will result in it being returned unprocessed thereby resulting in adelay or denial of eligibility to bid or do business with the City of Champaign.Section I. Identification1. Company Name and Address:PLEASE PRINTd/b/a:Chief Executive Officer:Address:City/State/Zip:Telephone: ( ) _______ - ____________ Fax: ( ) ________- ____________FEI Number:E-mail Address:Check one of the following:Social Security Number:Corporation Partnership Individual Proprietorship Limited Liability Corp.2. Name and Address of the Company’s Principal Office (answer only if not the same as above):Name:Address:3. Major activity of your company (product or service):City/State/Zip:4. Nature of Business:Contract:Bid:Register as a new vendor for future projects.Other:
Page 1 and 2: INVITATION TO BIDDate of Invitation
Page 3 and 4: understand the difficulties and res
Page 5 and 6: 11. Reservation of RightsA. The Cit
Page 7 and 8: SECTION 2 - TECHNICAL SPECIFICATION
Page 9 and 10: components with new parts or recond
Page 11 and 12: Contractor has fallen behind the se
Page 13 and 14: 9. I hereby attach my schedule of U
Page 15 and 16: SURETY: (Name)(SEAL)BY: (Signature
Page 17 and 18: STATE OF )COUNTY OF )) ss.I, , a No
Page 19 and 20: Authority Act, or the Build Illinoi
Page 21 and 22: 10. Accident PreventionThe Vendor s
Page 23 and 24: 17. Indemnity/Hold HarmlessTo the f
Page 25 and 26: 21. Performance Bond NOT APPLICABLE
Page 27 and 28: (B)The Construction Contractor shal
Page 29: C. PARTNERSHIP OR L.L.C.The busines
Page 33 and 34: SECTION III. Employment Information

INVITATION TO BID - City of Champaign

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