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RESPONDENT QUESTIONNAIRE
1. COMPANY AMEE AND TYPE OF ORGANIZATION:
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2. NAME AND TITLE OF AUTHORIZED CONTRACT SIGNER(S):
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3. ADMINISTRATIVE PERSONNEL: LIST NAMES, EMAIL AND PHONE NUMBER OF
ADMINISTRATIVE PERSONNEL WHO WILL ACTIVELY MONITOR ANY REQUEST FOR
QUOTES THAT IS EMAILED:
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4. (FIELD SUPERVISORS): LIST NAME,TITLE AND YEARS OF EXPERIENCE:
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5. LIST WORK YOU ARE UALIFIED TO PERFORM` WITH
�,YOUR OWN FO CES:
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6. LIST WORK NORMALLY SUBCONTRACTED TO OTHERS:
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‘iirr City of Sunny Isles Beach I Request for Qualifications No. 19-02-02 27
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7. HOW MANY EMPLOYEES DO YOU CURRENTLY MPLOY?(LOCALLY ND NATIONALLY)
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8. FIVE MOST RECENT CONTRACTS COMPLETED TO DATE: PROVIDE TOTAL STAGING
CONTRACT AMOUNT,YEAR,HOSTED BY,#OF AUDIENCE AND WHETHER THE EVENT
WAS
INDOORS OR OUTDOORS.
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9. UST A MINIMUM OF THREE(3) REFERENCES(PROVIDE FIRM NAME,ADDRESS,AND
CONTACT/PHONE/EMAIL)OF CURRENT AND PAST CUSTOMERS, PREFERABLY
GOVERNMENT AGENCIES OF WHICH YOU HAVE PROVIDED SERVICES SIMILAR IN / /�
SCOPE: R1 /P// 7 Co')4
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City of Sunny Isles Beach I Request for Qualifications No. 19-02-02 28
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10. WHICH GROUP DOES YOUR FIRM INTEND TO BE PRE-QUALIFIED FOR?GROUP 1
AND/OR GROUP 2?(SUBJECT TO CITY'S DISCRETION.)
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11. EXPLAIN YOUR COMPANY'S BACKGROUND CHECK PROCEDURES:
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12. EXPLAIN AN EXPERIENCE WHEN YOUR COMPANY WENT ABOVE AND BEYOND FOR A
CUSTOMER:
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13. HOW MANY DAYS'NOTICE WILL YOUR FIRM WANT THE EVENT SPECIFICATIONS,IN
EFFORTS TO QUOTE AND HAVE THE EQUIPMENT AVAILABLE FOR THE EVENT?
14. HAS YOUR FIRM EVER BEEN DEBARRED OR SUSPENDED FROM BIDDING OR
PROPOSING ON A PROCUREM NT PROJECT BY ANY GOVERNMENT ENTITY DURING THE
LAST FIVE(5)YEARS?
ATTACHMENTS:
ATTACH A LIST OF MAJOR EQUIPMENT YOU OWN,INDICATING TYPE,CAPACITY,YEAR,
MANUFACTURER, ETC.
Nfiler City of Sunny Isles Beach 'Request for Qualifications No. 19-02-02 29
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DELIVER TO: REQUEST FOR
City of Sunny Isles Beach QUALIFICATIONS OPENING: 2:00 P.M.
City Clerk SECTION 6 3/4/2019
18070 Collins Avenue RFQ SUBMITTAL FORMS
Sunny Isles Beach, FL 33160
PLEASE QUOTE PRICES F.O.B. DESTINATION, LESS TAXES, DELIVERED IN
CITY OF SUNNY ISLES BEACH, FLORIDA
NOTE: City of Sunny Isles Beach is exempt from all taxes(Federal, State,and Local). Bid price should be
less all taxes.Tax Exemption Certificate furnished upon request.
Issued by: Purchasing Agent Date Issued: This Bid Submittal Consists of
Genesis Cuevas 2/6/2019 Pages 30+
Sealed RFQs are subject to the Terms and Conditions of this Request for Qualifications and
the accompanying Submittal. Such other contract provisions, specifications, drawings or other data as
are attached or incorporated by reference in the Bid Submittal, will be received at the office of the City
Clerk at the address shown above until the above stated time and date, and at that time, publicly
opened for furnishing the supplies or services described in the accompanying Bid Submittal Requirement.
19-02-02
Pre-qualification for Stage Production Services on an As-Needed Basis
Purchasing Agent: Finn Name:
Genesis Cuevas j&A-1 {,/d/e? /./
Commodity Codes):
RETURN ONE ORIGINAL AND FOUR COPIES OF BID SUBMITTAL PAGES AND AFFIDAVITS
FAILURE TO SIGN PAGE 33 OF SECTION 6 RFQ SUBMITTAL WILL RENDER YOUR RESPONSE
NON-RESPONSIVE
ittov City of Sunny Isles Beach I Request for Qualifications No. 19-02-02 30
,e41.0"is,
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SECTION 6
BID SUBMITTAL FORM:
ACKNOWLEDGEMENT OF ADDENDA
INSTRUCTIONS: COMPLETE PART I OR PART II, WHICHEVER APPLIES
PART I:
LIST BELOW ARE THE DATES OF ISSUE FOR EACH ADDENDUM RECEIVED IN CONNECTION
WITH THIS BID
Addendum #1, Dated
Addendum #2, Dated
Addendum #3, Dated
Addendum #4, Dated
Addendum #5, Dated
Addendum #6, Dated
Addendum #7, Dated
Addendum #8, Dated
PART II:
❑ NO ADDENDUM WAS RECEIVED IN CONNECTION WITH THIS BID
FIRM NAME: �i^C,1< ACt.et In 0'1
AUTHORIZED SIGNATURE. .)?I #7r' FATE: 3/hY
1 ,
TITLE OF OFFICER: 1/tt! G Prt0 Ger\
Air
City of Sunny Isles Beach I Request for Qualifications No. 19-02-02 31
y�NM1'It�F
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C'r'Of 5k:14 rho
BID SUBMITTAL FORM
Stage Production Services on an As Needed Basis
The undersigned Proposer proposes and agrees, if this Bid is accepted, to enter into an agreement with
the City of Sunny Isles Beach to perform and furnish all Services as specified or indicated in the Contract
Documents for the Contract Price and within the Contract Time indicated in this Bid and in accordance with
the other terms and conditions of the Contract Documents.
The Proposer accepts all of the terms and conditions of the Advertisement or Invitation to Bid and
Instructions to Proposers, including without limitation those dealing with the disposition of Bid Security.
This Bid will remain subject to acceptance for 90 days after the day of Bid opening. The Proposers agrees
to sign and submit the Agreement with the Bonds and other documents required by the Bidding
Requirements within ten days after the date of the City's Notice of Award.
In submitting this Bid,the Proposer represents,as more fully set forth in the Agreement,that:
• The Proposer has familiarized himself/herself with the nature and extent of the
Contract Documents, Work, site, locality, and all local conditions and Law and
Regulations that in any manner may affect cost, progress, performance, or
furnishing of the Work.
• The Proposer has studied carefully all reports and drawings of subsurface
conditions and drawings of physical conditions.
• The Proposer has given the City written notice of all conflicts,errors,discrepancies
that it has discovered in the Contract Documents and the written resolution thereof
by City is acceptable to the Proposer.
• This Bid is genuine and not made in the interest of or on behalf of any undisclosed
person,firm or corporation and is not submitted in conformity with any agreement
or rules of any group, association, organization, or corporation; the Proposer has
not directly or indirectly induced or solicited any other Proposers to submit a false
or sham Bid; the Proposer has not solicited or induced any person, firm or
corporation to refrain from Bidding; and Proposer has not sought by collusion to
obtain for itself any advantage over any other Proposers or over the City.
The City and the successful Proposer will establish completion times for each individual Work Item and the
successful Proposer agrees that the work will be completed within the time frames agreed upon and
stipulated in the Notice to Proceed.
Lor City of Sunny Isles Beach I Request for Qualifications No. 19-02-02 32
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Firm Name:
----TtfAs.z Uci f.nInc -- --- -_---- __--
Street Address:
5
5-)P Ala) 16 [ 54-rcr,4- Mao.vn; G�w-der�S f G 330fq
Mailing Address (if different):
Telephone No. 79 • S OZ..26 •16 Fax No. -- 0/4
Email Address: i g `� �r4t�iamik%t,tdifiN No. Z/6-Y/ I/L/1/L/�/0
*"By signing this document the vendor agrees to all Terms
Signat
(Signature of authorized agent)
Print Name: �- &L1CQt.�r1
"
Title (�gd1t
THE EXECUTION OF THIS FORM CONSTITUTES THE UNEQUIVOCAL OFFER OF PROPOSER TO
BE BOUND BY THE TERMS OF ITS PROPOSAL. FAILURE TO SIGN THIS SOLICITATION WHERE
INDICATED ABOVE BY AN AUTHORIZED REPRESENTATIVE SHALL RENDER THE PROPOSAL
NON-RESPONSIVE. THE CITY MAY, HOWEVER, IN ITS SOLE DISCRETION, ACCEPT ANY
PROPOSAL THAT INCLUDES AN EXECUTED DOCUMENT WHICH UNEQUIVOCALLY BINDS THE
PROPOSER TO THE TERMS OF ITS OFFER.
City of Sunny Isles Beach I Request for Qualifications No. 19-02-02 33
SUNNY isLf
Eo-:. ,n
NON - COLLUSION AFFIDAVIT
u ^' 1 z
City of Sunny Isles Beach
A .1*\1.,1_41 _____)
18070 Collins Avenue
L l'e ''•FLOW".o+: Sunny Isles Beach,FL 33160
' o, sus"� Telephone:(305)947-0606 Fax:(305)949-3113
STATE OF FLORIDA )
COUNTY OF '11041'1 I Dock- ,
The undersigned being first duly sworn as provided by law,deposes,and says:
This Affidavit is made with the knowledge and intent that it is to be filed with the City of Sunny Isles Beach City Commission and that it will be
relied upon by said County,in any consideration which may give to and any action it may take with respect to this Bid.
The undersigned is authorized to make this Affidavit on behalf of,
Trc 4CAdD /, 4-
(Name of Corporation, Partnership, Individual,etc.)
a,ji. 41 On �r YlC Sormed under the laws of Floc l cicr-
(Type of Business) (State)
of which he is Vico._ Pre 18 en
(Sole Owner, Partner, President,etc.)
Neither the undersigned nor any person, firm, or corporation named in above Paragraph 10.2, nor anyone else to the knowledge of the
undersigned, have themselves solicited or employed anyone else to solicit favorable action for this Bid by the City, also that no head of any
department or employee therein,or any officer of the City of Sunny Isles Beach,Florida is directly interested therein.
This Bid is genuine and not collusive or a sham;the person,firm or corporation named above in Paragraph 10.2 has not colluded,conspired,
L
,
connived or agreed directly or indirectly with any proposers or person, firm or corporation,to put in a sham Bid, or that such person, firm or
corporation, 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, firm or corporation,to fix the prices of said Bid or Bids of any other proposers;and all statements contained in
the Bid or Bids described above true; and further; neither the undersigned, nor the person, firm or corporation named above in Paragraph
10.2,has directly or indirectly submitted said Bid or the contents thereof,or divulged information or data relative thereto,to any association or
to any member or agent thereof.
sem g,-- ��� yie.c Pcs (d.cix
�AFFIANT'S NAME AANT'S TITLE
TAKEN, SWORN AND SUBSCRIBED TO BEFORE ME this Lfitday of M 4vd, ,mot
Personally Knownor Produced Identification p// . ,
Type of identification ED('''63cZ.leq-82df44'0
1
(Affix seal here) I
tin J . llt� 'V
NOTARY PUBLIC(nam- printed ofd' .'--d) 4
r• Y,,%'••• TRINIACOWERT
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DECBBABER 28,2010
ti�NY is,f� 7
�_ PUBLIC ENTITY CRIMES
:-5
•
\ a City of Sunny Isles Beach
,D\ �4' 18070 Collins Avenue
klIF 4e- ?.F S OW' 5 Sunny Isles Beach,FL 33160
�'''o. SUS�'° Telephone:(305)947-0606 Fax:(305)949-3113
SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(a)
FLORIDA STATUTES,ON PUBLIC ENTITY CRIMES
PUBLIC ENTITY CRIMES
Pursuant to the provisions of paragraph (2) (a) of Section 287.133, Florida State Statutes - "A person or affiliate
who has been placed on the convicted vendor list following a conviction for a public entity crime may not submit a
Bid on a Contract to provide any goods or services to a public entity, may not submit a Bid on a Contract with a
public entity for the construction or repair of a public building or public Work, may not submit Bids on leases of
real property to a public entity, may not be awarded to perform Work as a Contractor, supplier, Sub-Contractor, or
Consultant under a Contract with any public entity, and may not transact business with any public entity in excess
of the threshold amount Category Two of Sec. 287.017, FS for thirty six months from the date of being placed on
the convicted vendor list".
THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER
OFFICIAL AUTHORIZED TO ADMINISTER OATHS.
11.1. This swo statement is sub`�itted to City of Sunny Isles Beach
� 1 •
b 6,our-1- �` _e-— pros 'CA
y S4-
(pnnt individual's n• e an. .le]
for Ti(A Z ', A 10 , I�'1L°
[punt name of enti y su.m i mg swor statement]
whose business address is: 56-76 icu ' c I s4 rt . 1 v11 gym:
d, ,s, FL 336 ! y
and (if applicable) its Federal Employer Identification number(FEIN) is 26-- cif z-7 5.410
(If the entity had nR'F X, include the Social Security Number of the individual signing this sworn
statement: 'T/�- .)
11.2. I understand that a "public entity crime" as defined in Paragraph 287.133(1)(g), Florida Statutes, means a
violation of any state or federal law by a person with respect to and directly related to the transaction of
business with any public entity or with an agency or political subdivision of any other state or with the
United States, including, but not limited to, any Bid or Contract for goods or services to be provided to any
public entity or an agency or political subdivision of any other state of the United States and involving
antitrust, fraud,theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation.
11.3. I understand that "convicted" or"conviction" as defined in Para. 287.133(1)(b), Florida Statutes, means a
finding of guilt or a conviction of a public entity crime, with or without an adjudication of guilt, in any
federal or state trail court of record relating to charges brought by indictment or information after July 1,
1989, as a result of a jury verdict, non-jury trial, or entry of a plea of guilty or nob contendere.
11.4. I understand that an "affiliate" as defined in Para. 287.133(1)(a), Florida Statutes, means:
a.) predecessor or successor of a person convicted of a public entity crime; or
b.) Any entity under the control of any natural person who is active in the management of the entity
and who has been convicted of a public entity crime. The term "affiliate" includes those officers,
directors, executors, partners, shareholders, employees, members, and agents who are active in
the management of an affiliate. The ownership by one person of shares constituting a controlling
interest in another person, or a pooling of equipment or income among persons when not for fair
DECEMBER 28,2010
market value under an arm's length agreement, shall be a prime facie case that one person
controls another person. A person who knowingly enters into a joint venture with a person who
has been convicted of a public entity crime in Florida during the preceding 36 months shall be
considered an affiliate.
11.5. I understand that a "person" as defined in Para. 287.133(1)(e), Florida Statutes, means any natural
person or entity organized under the laws of any state or of the United States with the legal power to
enter into a binding Contract and which Bids or applies to Bid on Contracts for the provision of goods or
services let by a public entity, or which otherwise transacts or applies to transact business with a public
entity. The term "persons" includes those officers, directors, executives, partners, shareholders,
employees, members, and agents who are active in management of any entity.
11.6. Based on information and belief, the statement which I have marked below is true in relation to the entity
submitting this sworn statement. (Indicate which statement applies.)
Neither the entity submitting this sworn statement, nor any of it's officers, directors, executives, partners,
shareholders, employees, members, or agents who are active in the management of the entity, nor any
affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1,
1989.
The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners,
shareholders, employees, members, or agents who are active in the management of the entity, or an
affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1,
1989.
The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners,
shareholders, employees, members, or agents who are active in the management of the entity, or an
affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1,
1989. However, there has been a subsequent proceeding before a Hearing Officer of the State of
Florida, Division of Administrative Hearings and the Final Order entered by the Hearing Officer of the
State of Florida, Division of Administrative Hearings and the Final Order entered by the Hearing Officer
determined that it was not in the public interest to place the entity submitting this sworn statement on the
convicted vendor list. (Attach a copy of the final order.)
I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR THE
PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 11.1 (ONE)ABOVE IS FOR THAT PUBLIC ENTITY ONLY AND,
THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS FILED. I
ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO
A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION 287.017, FLORIDA
STATUTES, FOR CATEGORY TWO OF ANY, CHANGE IN THE INFO'MATION CONTAINED IN THIS FORM.
By. .' .i�_ _
( ignature)
�L
RA •
(Printed Name .
V Prci S
(Title)
Sworn to and subscribed before me this / day of AAA r - , 20 11 , by
617,V Lei - , .471 n Lr y-
(AFFIX NOTARY STA u' �/�'— . OP
d , TRINIACOWERT I
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LPersonally Known OR Produced Identification 53S-2-75'03 if 6s--14•d 10/1998
� tiNY1
S4FJ
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,Ir �= EQUAL OPPORTUNITY /
�: AFFIRMATIVE ACTION
kw ''::,",,,c). City of Sunny Isles Beach
'NO 18070 Collins Avenue
Sunny Isles Beach,FL 33160
Telephone:(305)947-0606 Fax (305)949-3113
EQUAL OPPORTUNITY/AFFIRMATIVE ACTION STATEMENT
The contractors and all subcontractors hereby agree to a commitment to the principles and
practices of equal opportunity in employment and to comply with the letter and spirit of
federal, state, and local laws and regulations prohibiting discrimination based on race,
color, religion, national region, sex, age, handicap, marital status, and political affiliation or
belief.
Signed: ` /
Title: Y 16 C.,. ePre-Stcl�4 -
Firm: 4-Tr(At , NA cli O ' IAC,
Address: 6 5 V`fW ( 61 54 -.)--reeT
iiiitri 6 c efts r Fl 3Ofi(
DECEMBER 28,2010
SUNNY is,e
.4 Jd
CONFLICT OF INTEREST
t; City of Sunny Isles Beach
,D ' 18070 Collins Avenue
'''.. '•c L o" o' Sunny Isles Beach,FL 33160
,
'.o, sys''' Telephone:(305)947-0606 Fax:(305)949-3113
CONFLICT OF INTEREST STATEMENT
The award of any contract hereunder is subject to the provisions of Chapter 112, Florida State Statutes. Proposers must
disclose with their Bids, the name of any officer, director, partner, associate or agent who is also an officer or employee of the
City of Sunny Isles Beach or its agencies.
STATE OF FLORIDA
COUNTY OF
BEFORE ME, the undersigned authority, personally appeared , who was duly sworn,
deposes, and states:
18.1. I am the of
with a local office in and principal office in
18.2. The above named entity is submitting a Bid for the City of Sunny Isles Beach, Bid No. described
as: Landscape Maintenance Services. The Affiant has made diligent inquiry and provides the information contained in this
Affidavit based upon his own knowledge.
18.3 The Affiant states that only one submittal for the above Bid is being submitted and that the above named entity has
no financial interest in other entities submitting Bids for the same project.
18.4 Neither the Affiant nor the above named entity has directly or indirectly entered into any agreement, participated in
any collusion, or otherwise taken any action in restraints of free competitive pricing in connection with the entity's submittal for
the above Bid. This statement restricts the discussion of pricing data until the completion of negotiations if necessary and
execution of the Contract for this project.
18.5 Neither the entity nor its affiliates, nor any one associated with them, is presently suspended or otherwise ineligible from
participation in contract letting by any local, State, or Federal Agency.
18.6 Neither the entity, nor its affiliates, nor any one associated with them have any potential conflict of interest due to any
other clients, contracts, or property interests for this project.
18.7 I certify that no member of the entity's ownership or management is presently applying for any employee position or
actively seeking an elected position with the City of Sunny Isles Beach.
18.8 I certify that no member of the entity's ownership or management, or staff has a vested interest in any aspect of the City
of Sunny Isles Beach.
18.9 In the event that a conflict of interest is identified in the provision of services, I, on behalf of the above named entity, will
immediately notify the City of Sunny Isles Beach.
".....;:d42.......' ' 44% /day • >ii .:Kill 201$
fejt
AFFIANT Print or Type Name and Title
Sworn to and subscribed before me this 'T- day of AlGI<,✓G.h , 2019.
O Personally Known OR 7� -^N
Produced Identification ; Type of Ide cations a_+�L �3S2. ID 'bSti-`d
itd.2.. alluter
NOTARY PUBLIC STATE OF FLORIDA
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DECEMBER 28,2010
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�� DISPUTE DISCLOSURE
" City of Sunny Isles Beach
A ',Ds o f W� 18070 Collins Avenue
%F '•f s o 9'‘ Q Sunny Isles Beach,FL 33160
Le o. ,�� 'N Telephone:(305)947-0606 Fax:(305)949-3113
DISPUTE DISCLOSURE FORM
Answer the following questions by placing a "X" after "Yes" or "No". If you answer "Yes", please
explain in the space provided,or on a separate sheet attached to this form.
19.1. Has your firm or any of its officers, received a reprimand of any nature or been suspended by the
Department of Professional Regulations or any other regulatory agency or professional associations within the last
five (5) years?
YES NO 7C
19.2. Has your firm, or any member of your firm, been declared in default, terminated or removed from a
contract or job related to the services your firm provides in the regular course of business within the last five (5)
years?
YES NO X
19.3. Has your firm had against it or filed any requests for equitable adjustment, contract claims, Bid protests,
or litigation in the past five (5) years that is related to the services your firm provides in the regular course of
business?
YES NO )(
Ifes, state the nature of the request for
y eq equitable adjustment, contract
claim, litigation, or protest, and state a brief description of the case, the outcome or status of the suit and the
monetary amounts of extended contract time involved.
I hereby certify that all statements made are true and agree and understand that any misstatement or
misrepresentation of falsification of facts shall be cause for forfeiture of rights for further consideration of this Bid
for the City of Suny Isles Beach.
I r(4 e_ (A4 g
I
n Inl_L /19‘
Firat�ei-eie Se,-1-and.cm1(4"
Authorized Signature Print or Type Name and Title
DECEMBER 28,2010
° SJµNV Is
ANTI — KICKBACK
• City of Sunny Isles Beach
',9a, ` �t 18070 Collins Avenue
cif z •F SUS'Ho 5 Sunny Isles Beach,FL 33160
' o, SUS Telephone:(305)947-0606 Fax (305)949-3113
ANTI-KICKBACK AFFIDAVIT
STATE OF FLORIDA )
COUNTY OF VO4,i1I D444
I, the undersigned, hereby duly sworn and deposed say that no portion of this sum herein Bid
will be paid to any employees of the City of Sunny Isles Beach or its elected officials as a
commission, kickback, reward or gift, directly or indirectly by me or any member of my firm or
by an officer of the corporation.
By:
Title:
t%Aar44
The foregoing instrument was acknowledged before me this T day of
20 1 ct , by �Yar>r P e4s-,cav e'{— [name
of person], as ViC� ?re,,aidtrafi[type of authority], for
[name of party on behalf of whom instrument was
executed]. /
AFFIX NOTARY STAMP HERE: V.—dab 1110:
�Nr4:.i TRINIACOWERT . Nota Public Florida
Florida
,•, '; ; MY COMMISSION#GG 046113
s*•a +. = EXPIRES:December 4,2020 1.1 C—.a
N.ABonded Thru Notary Public UndeIwtters
Print or Type Commissioned Name
Personally Known OR Produced Identification ,x
Type of Identification Produced fi_DL P35•Z-'1 f4— /-I—DV-1-0
L
DECEMBER 28,2010
SVµN''SF
T
(kwCONTRACTOR ANTI-BOYCOTT CERTIFICATION
E, �rioa.
[PURSUANT TO FLORIDA STATUTE§215.4725]
I, 6i-Q.✓1 e2, n behalf of T—ru.c., A(A1 c, i,c
Print Name Company Name
certifies that J rue, ACAC1 10 � Ifrxe_ does not:
Company Name
1. Participate in a boycott of Israel; and
2. Is not on the Scrutinized Companies that Boycott Israel list; and
3. Is not on the Scrutinized Companies with Activities in Sudan List; and
4. Is not on the Scrutinized Companies with Activities in the Iran Petroleum
w Energy Sector List; and
5. Has not engaged in business operations in Cuba or Syria.
Signature
Pre,Si ct-e,n�Tiyice_,
3 41- /47
Date
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