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THE SCHOOL DISTRICT OF PALM BEACH COUNTY, FLORIDA (School District of Indian River County)

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1
Revised 10-2-20
THE SCHOOL DISTRICT OF PALM BEACH COUNTY, FLORIDA
NEW VENDOR
PREQUALIFICATION PROGRAM
Pursuant to State Requirements for Educational Facilities, Chapter 4, Section 4.1 “Prequalification
of Contractors for Educational Facilities Construction”, Prequalification is applicable to Bids
(Invitations to Bid), RFP (Request For Proposal), Construction Management at Risk (CMAR),
Design/Build (D/B) and any other Construction Services for a Construction Project with an
estimated construction budget of $300,000 or more. The criteria established for Prequalification
is in accordance with Chapter 489, Florida Statutes, (SREF) 2014, School Board 7.08 and all other
applicable rules, regulations and procedures.
The required method for receipt of New Vendor Application is via email sent to
Construction Contractor Prequalification at: Prequal@palmbeachschools.org.
Contractors currently Prequalified with the School District of Palm Beach County
are required to submit a Renewal Application each year to maintain the Prequalified
status.
2
Revised 10-2-20
THE SCHOOL DISTRICT OF PALM BEACH COUNTY, FLORIDA
APPLICATION FOR
NEW VENDOR
PREQUALIFICATION PROGRAM
Construction Purchasing Department
3661 Interstate Park Rd. N., Suite 233
Riviera Beach, FL 33404
The required method for receipt of New Vendor Application is via e-mail sent to
Construction Contractor Prequalification at:
Prequal@palmbeachschools.org.
3
Revised 10-2-20
THE SCHOOL DISTRICT OF PALM BEACH COUNTY, FLORIDA
APPLICATION FOR NEW
VENDOR PREQUALIFICATION PROGRAM
TABLE OF CONTENTS
TITLE OF SECTION PAGE
1. COVER PAGE ............................................................................................................... 1
2. TITLE PAGE ................................................................................................................. 2
3. TABLE OF CONTENTS ................................................................................................ 3
4. INSTRUCTIONS FOR SUBMITTAL OF APPLICATION ............................................. 4 - 6
5. APPLICATION FOR PREQUALIFICATION (Parts 1 - 6) .......................................... 7 - 13
EXHIBITS:
A. PUBLIC ENTITY CRIMES STATEMENT ................................................................. 2
B. AFFIDAVIT OF TRUTH ......................................................................................... 1
C. INSURANCE REQUIREMENTS ............................................................................. 1
D. DISCLOSURE OF DISCRIMINATION COMPLAINTS ............................................. 1
E. DISCLOSURE OF DISQUALIFYING CRIMES ......................................................... 1
F. LETTER OF INTENT FROM BONDING AGENT/SURETY ....................................... 1
G. BENEFICIAL INTEREST AND DISCLOSURE OF OWNERSHIP AFFIDAVIT
(PBSD 1997) ........................................................................................................... 1
4
Revised 10-2-20
INSTRUCTIONS FOR
SUBMITTAL OF APPLICATION
1. GENERAL INFORMATION: The School District of Palm Beach County ("District") invites qualified
Contractors to apply for the District's Vendor Prequalification Program.
Pursuant to State Requirements for Educational Facilities, Chapter 4, Section 4.1 “Prequalification of
Contractors for Educational Facilities Construction”, Prequalification is applicable to Bids (Invitations to Bid),
RFP (Request For Proposal), Construction Management at Risk (CMAR), Design/Build (D/B) and any other
Construction Services for a Construction Project with an estimated construction budget of $300,000 or more.
The criteria established for Prequalification is in accordance with SREF, Florida Statutes Ch. 489, School Board
Policy 7.08 and all other applicable rules, regulations and procedures. Contractors shall be Prequalified by the
Board to be eligible to offer a Bid or submit a Proposal in response to an ITB/RFP. A Contractor shall be approved
for bonding capacity not less than the established Construction Budget for the Project for which the Contractor
is submitting a Bid or Proposal.
2. INSTRUCTIONS FOR SUBMITTAL: This Application applies only to those firms that have not previously
submitted an Application for Prequalification or have a Prequalification that has expired. Vendors that have
previously applied and/or have been recommended to the School Board need not apply as their application has
already been reviewed and processed. Vendors must be prequalified prior submittal of a Bid/Proposal to be
eligible for Award. Firms are not required to be prequalified to act as subcontractors.
It is the sole responsibility of the applicant to ensure the application is received by the District.
Incomplete, inaccurate or omission of information may be cause for rejection of an application or may delay
processing of the application through approval by the School Board. ALL VENDOR INFORMATION MUST
BE COMPLETED AND SAVED AS ONE (1) OPTIMIZED PDF FILE INCLUDING ALL EXHIBITS AS
LISTED ON PAGE 5 OF THIS PACKET. The required method for receipt of new/renewal
applications is via e-mail to PREQUAL@PALMBEACHSCHOOLS.ORG. Completed applications,
meeting all requirements for submittal which includes the fully completed application form and attached
documents outlined in the application packet, will be processed within sixty (60) days of receipt of the
application.
Applications must be received prior to the first business day of each month to be eligible for processing and
potential recommendation for approval by the School Board at a following month’s School Board Meeting.
Applications received after each established cut-off date, including application received with incomplete or
missing submittal requirements, will be added to a subsequent review and approval process.
The Construction Disciplines to be subject to this Prequalification Process are as follows:
CS/SD: Construction Services and Site Development (General Contractor or Building
Contractor)
DS: Demolition Services (General Contractor)
ES: Electrical Services (Electrical Contractor)
FA: Fire Alarm System Services (Electrical Contractor or Alarm System Contractor
HV: HVAC Services (Mechanical Contractor or A/C Contractor - Class A or B)
PS: Painting Services (Palm Beach County Certificate of Competency)
RS: Roofing Services (Roofing Contractor)
UU: Utility and Underground Excavation Services (Underground Utility Contractor)
5
Revised 10-2-20
Each Proposer shall use the Forms and Exhibits contained in this Application. Proposals
containing any conditions, omissions, unexplained erasures, alternates, items not called for or
irregularities of any kind may be rejected. The School Board reserves the right to waive minor
irregularities in the Proposals, or to reject all Proposals.
In every case, the name of the person signing, and his designation, shall be typed or
printed below his signature. A Proposal by a person who affixes to his signature the word
"President", "Secretary", "Owner" or other designation without disclosing his principal may be held to
be the Proposal of the individual so signing. Satisfactory evidence of the authority of an officer, owner,
attorney, or other person signing for a corporation and for an owner, attorney, etc., signing for a
partnership or an individual shall be furnished.
The following documents are Required Documents for the Application Package to be
considered responsive and accepted for consideration for Prequalification:
1. Application for Prequalification (Parts 1 - 6) Pages 7-13 of this Packet
2. Public Entity Crime Certification - Exhibit A
3. Affidavit of Truth - Exhibit B
4. Certificate of Insurance (evidencing required coverage) - Exhibit C
5. Disclosure of Discrimination Complaints Statement - Exhibit D
6. Disclosure of Disqualifying Crimes Statement - Exhibit E
7. Letter of Intent from Bonding Agent/Surety - Exhibit F
8. Beneficial Interest and Disclosure of Ownership - Exhibit G
9. Certificate of Incorporation ACTUAL CERTIFICATE – USE FOLLOWING
LINK TO ORDER: www.SunBiz.org - Current Year
10. Contractor's Licenses for each Construction Discipline - Current Year
11. Business Occupational License/Tax Receipt - USE FOLLOWING LINK TO
ORDER: https://www.pbctax.com/services/local-business-tax-services -
Current Year
3. QUALIFICATIONS: A complete application must be submitted in order to be considered for
prequalification. Applicants may have their application rejected if the application is:
a. is incomplete, or
b. does not substantiate their ability to be successful in carrying out the performance of the work, or
c. reveals, within the five (5) year period ending with the date the contractor submits its prequalification
application, that the contractor has been convicted, is or has been under investigation or has a pending
civil or criminal claim related to fraud, false statement or misrepresentation in connection with the
contractor’s obtaining or performance of any contract, or
d. that contractor has a systemic pattern of litigation activity. Failure to disclose any investigation,
claim or suit or to provide any requested information in connection with contractor’s
litigation history will result in the School Board, through their designee, rejecting an
Application for Prequalification.
No bid or proposal for school construction shall be accepted from a contractor whose certificate has
been revoked, suspended, expired, or declared delinquent. Prequalified Contractors must be capable
of fulfilling specific project requirements for bonding, insurance, staffing, completion dates and work
quality.
6
Revised 10-2-20
4. APPLICATION MODIFICATION: Modification of the Application Package will be accepted from
Proposers if addressed to the Owners, at the place where Proposals are to be received. Modifications
shall be in writing. The requirements set forth in Section 2 pertaining to signatures on Proposals, shall
be applicable to the signatures on all modifications.
5. WITHDRAWAL OF APPLICATIONS: Applications may be withdrawn on written request
received from the applicant. Such request shall be properly signed in accordance with the
requirements pertaining to signatures contained in section 2.
6. LOBBYING: Applicants are hereby advised that lobbying is not permitted with any District
personnel or Board members related to or involved with Vendor Prequalification. All oral or written
inquiries must be directed through the Construction Purchasing Department.
Lobbying is defined as any action taken by an individual, firm, association, joint venture, partnership,
syndicate, corporation, and all other groups who seek to influence the decision of a Board member or
District personnel on the approval of an Application Package.
Any applicant or any individuals that lobby on behalf of proposer during the time specified may result
in rejection or disqualification.
7. PROCEDURE FOR PREQUALIFICATION: Procedures and criteria for prequalifying responsive
and responsible Contractors for school construction projects for the School District of Palm Beach
County have been established in accordance with Section 235.31 Florida Statutes, and State
Requirements for Educational Facilities.
Applications will be reviewed by a Committee comprised of District employees duly assigned to
evaluate those applications. After examination and evaluation of the submitted applications, the
Committee shall recommend to the Director of Purchasing the acceptance or rejection of each
applicant.
The Committee will evaluate all applications and make recommendations for type of project, dollar
volume and limits allowed within the scope or Prequalification. Contractors shall be prequalified by
the Board on the basis of the information contained in their proposals and as recommended by the
Director of Purchasing and the Superintendent of Schools.
8. PREQUALIFICATION PERIOD: District prequalified vendors may participate in Invitations to
Bid and Request for Proposals for their applicable Disciplines for a one (1) year period from the
date of approval of the vendors certification by the School Board of Palm Beach County.
9. LETTER OF APPROVAL: A letter of Approval shall be sent to all applicants’ who are Board
approved as Prequalified Vendors. The letter will include:
A statement indicating the effective dates during which the contractor may bid for applicable projects
A statement establishing the classification of work the contractor is approved to provide.
A statement establishing the dollar value of work the contractor is approved to Bond.
The School District reserves the right to revoke, suspend and/or disqualify vendors who have been
prequalified under this program for cause. Such action, if it occurs, will be taken at an administrative
hearing at a publicly noticed time, date and place. Firms who are suspended, revoked, or disapproved
may not resubmit a new application during the period of suspension or revocation, or at least 12
months within the date of disapproval.
END OF SECTION
7
Revised 10-2-20
Vendor Name: ______________________________
Date of Application Submittal: _________________________
SCHOOL DISTRICT OF PALM BEACH COUNTY
APPLICATION FOR
NEW
VENDOR PREQUALIFICATION PROGRAM
VENDOR INFORMATION
The Vendor shall complete Items 1 - 6 of the Vendor Information in its entirety. The District
reserves the right to request and review additional information as may be required to determine
the vendor's qualifications.
1. CLASSIFICATION(S):
Specify one or more construction classification codes from the following list in which the
vendor is applying for Prequalification. Please note the required license:
SDPBC CONSTRUCTION CLASSIFICATION CODES & REQUIRED LICENSE:
CS/SD: Construction Services and Site Development (General Contractor/Building Contractor)
DS: Demolition Services (General Contractor)
ES: Electrical Services (Electrical Contractor)
FA: Fire Alarm System Services (Electrical Contractor or Alarm System Contractor
HV: HVAC Services (Mechanical Contractor or A/C Contractor - Class A or B)
PS: Painting Services (Palm Beach County Certificate of Competency)
RS: Roofing Services (Roofing Contractor)
UU: Utility and Underground Excavation Services (Underground Utility Contractor)
8
Revised 10-2-20
2. VENDOR INFORMATION:
Corporate Name: ______________________________________________________
Address: _____________________________________________________________
City/State/Zip: ________________________________________________________
Phone: _______________________ Email: _________________________________
Contact Person for Application: _______________________________________
Contact Person Email: ______________________________________________
Type of Organization (check one below):
_____ Corporation ______LLC ______ Partnership _____ Sole Proprietor
If Corporation, State of Incorporation: _____________________________________
Date of Incorporation: __________________________________________________
If Out-of-State Corporation, currently authorized to do business in the State of Florida;
provide date and proof of such authorization: ________________________________
FEIN NO.: _____________________________
NAME AND TITLE OF PRINCIPAL OFFICERS:
Name/Title: Date Elected:________________
_________________________________________________________________
_________________________________________________________________
Name of Qualifying Agent(s) and Date Elected:
Name/Title: Date Elected:_______________
_________________________________________________________________
____________________________________________________________
Name of Financially Responsible Officers:
Name/Title: Date Elected:_______________
__________________________________________________________________
_____________________________________________________________
9
Revised 10-2-20
If Partnership, list the names and Addresses of all Partners:
______________________________________________________________________
______________________________________________________________________
If Sole Proprietorship, list the name and address of Owner:
______________________________________________________________________
______________________________________________________________________
Has the owner, partner or any principal of the applicant declared bankruptcy?
_____Yes _____No
If yes, provide dates and particulars:
_______________________________________________________________________
_______________________________________________________________________
List any and all subsidiaries and/or holding companies.
_______________________________________________________________________
_______________________________________________________________________
List other Public Agencies the Applicant is currently prequalified and provide proof of
current prequalified status (letter, certificate, etc.).
AGENCY NAME
TRADE IN
WHICH
QUALIFIED
EXPIRATION
DATE
AMOUNT
APPROVED
10
Revised 10-2-20
3. LITIGATION DISCLOSURE:
Disclose all pending and resolved construction-related litigation and claims, including but not limited
to insurance claims, actions against or by an owner, engineer, architect, contractor, subcontractor,
materialman or supplier within the five (5) year period ending with the date the contractor submits its
prequalification application. Failure to disclose any claim, or to provide any requested
information in connection with a contractor’s litigation history will result in the
Superintendent or designee rejecting an Application for Prequalification. For purposes of this
disclosure requirement, a claim includes, lawsuits, administrative hearings and arbitrations. Disclose all
pending and resolved litigation, claims, charges, investigations, whether civil or criminal in nature, related
to fraud, false statement or misrepresentation in connection with the contractor’s obtaining or
performance of any contract within the five (5) year period ending with the date the contractor submits its
prequalification application. An adjudication of guilt or adjudication withheld; guilty plea; nolo
contendere and admission of liability may result in the Superintendent or designee rejecting the contractor
for prequalification. Failure to disclose any claim, or to provide any requested information in connection
with a contractor’s litigation history will result in the Superintendent or designee rejecting an application
for prequalification. For purposes of this disclosure requirement, a claim includes, lawsuits,
administrative hearings and arbitrations.
Provide the following information for each case/claim. If not applicable, please indicate as
N/A. Please attach additional pages if needed. For each claim which the Applicant is named
as the Defendant, provide evidence of final judgment demonstrating satisfactory resolution
of the claim filed:
a. Name the Plaintiff, Defendant, case number and date of each claim filed.
__________________________________________________________________
__________________________________________________________________
b. Provide the name, address, telephone number of the attorneys representing the
Plaintiff and Defendant.
__________________________________________________________________
__________________________________________________________________
c. Provide a description of the claim.
__________________________________________________________________
__________________________________________________________________
d. Current status of each claim.
__________________________________________________________________
__________________________________________________________________
4. BONDING CAPACITY: “Exhibit F" Letter of Intent from Bonding Agency must be with Application
Single Project Capacity (dollar amount): $______________________________________
Aggregate Capacity (dollar amount): $_________________________________________
11
Revised 10-2-20
Has the firm ever failed to complete a project that required a Performance Bond or a Payment of Material and Labor
Bond (or its equivalent) to be enacted?
No_______ Yes_______
If yes, provide circumstances including Owner Name, Project Name, Project Date and Value.
______________________________________________________________________________
5. EXPERIENCE:
For each construction discipline applied, provide at least three (3) projects of similar construction scope, each
with a value over $300,000, completed within the last three (3) years. Provide projects based on the
following criteria in descending order: 1) K-12 or other Educational Construction Experience; 2) Construction within
the State of Florida; 3) Construction for Governmental or Educational Organization; 4) Construction of Educational
and/or Public Facilities in other states. Please provide a response for all questions.
Applicant may provide additional experience on separate sheets and attached to this form,
but MUST include all of the information in the same format as below. Applicants may
include a letter of recommendation for each project listed.
PROJECT EXPERIENCE #1:
Project Name: _____________________________________________________________
Project Location (Address, City, State, Zip): _________________________________________
Contact Name: _______________________ Contact Email: ___________________________
Contact Phone Number: ______________________ Extension: ________________________
Contract Dollar Value: ______________________ Architect Name: ______________________
Was Project Completed on Schedule? Yes__ No__ Date Started: ______ Date Completed: ______
Percentage of Work Completed by Company: ____________ Were Bonds Required? ____________
If so, what type and how much: _________________________________________________
Type(s) of Work Performed (name disciplines, scope of work, etc.):
_______________________________________________________________________
_____________________________________________________________________
Other Performance Factors: ___________________________________________________
Was there an M/WBE Business Goal established? _________ Percentage Amount required? _______
What was the actual M/WBE percentage based on contract dollars? _________________________
0.00%
12
Revised 10-2-20
PROJECT EXPERIENCE #2:
Project Name: ____________________________________________________________
Project Location (Address, City, State, Zip): ________________________________________
Contact Name: ______________________ Contact Email: __________________________
Contact Phone Number: _______________________ Extension: ______________________
Contract Dollar Value: _______________________ Architect Name: ___________________
Was Project Completed on Schedule? Yes__ No__ Date Started: ______ Date Completed: ______
Percentage of Work Completed by Company: _____________ Were Bonds Required? _________
If so, what type and how much: ________________________________________________
Type(s) of Work Performed (name disciplines, scope of work, etc.)________________________
Other Performance Factors___________________________________________________
Was there an M/WBE Business Goal established? _______ Percentage Amount required? ______
What was the actual M/WBE percentage based on contract dollars? _______________________
PROJECT EXPERIENCE #3:
Project Name: ___________________________________________________________
Project Location (Address, City, State, Zip): _______________________________________
Contact Name: _______________________ Contact Email: _________________________
Contact Phone Number: ______________________ Extension: _______________________
Was Project Completed on Schedule? Yes__ No__ Date Started: ______ Date Completed: ______
Contract Dollar Value: _________________ Architect Name: __________________________
Percentage of Work Completed by Company: ___________ Were Bonds Required? ____________
If so, what type and how much: __________________________________________________
Type(s) of Work Performed (name disciplines, scope of work, etc.)__________________________
Other Performance Factors: ____________________________________________________
Was there an M/WBE Business Goal established? _______ Percentage Amount required? _______
What was the actual M/WBE percentage based on contract dollars? _________________________
13
Revised 10-2-20
6. CERTIFICATION:
Is the applicant certified as an SBE OR M/WBE by the School District of Palm Beach County?
_______ SBE and/or ______ M/WBE
Yes____ (If yes, attach a copy of the certificate)
No ____
Please identify M/WBE designation: ___________________________________________
(African American, Hispanic American, Asian American, Native American, Woman Owned or Service Disabled Veteran)
END OF SECTION
PUBLIC ENTITY CRIMES STATEMENT
SWORN STATEMENT UNDER SECTION 287.133 (3) (a)
FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES
THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICER
AUTHORIZED TO ADMINISTER OATHS.
This sworn statement is submitted to:
By
for
whose business address is
and (if applicable) its Federal Employer Identification Number (FEIN) is:
(If entity has no FEIN, include the Social Security Number of the Individual signing this sworn statement.)
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 of the
United States, including, but not limited to, any proposal or contract for goods or services to be provided
to any public entity or an agency or political subdivision of any other state or of the United States and
involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material
misrepresentations.
I understand that "convicted" or "conviction" as defined in Paragraph 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 trial 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 nolo contendere.
I understand that an "affiliate" as defined in Paragraph 287.133(1)(a), Florida Statutes, means:
(1) A predecessor or successor of a person convicted of a public entity crime; or
(2) An 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, executives, 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
market value under an arm's length agreement, shall be a prima 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.
Pag
e 1 of 2
(print name of public entity)
(print name of entity submitting sworn statement)
(print individual's name and title)
EXHIBIT A
THE SCHOOL BOARD OF PALM BEACH COUNTY
EXHIBIT A
I understand that a "person" as defined in Paragraph 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 submits proposals or applies to submit a proposal 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 "person" includes those officers, directors,
executives, partners, shareholders, employees, members, and agents who are active in management
of an entity.
Based on information and belief, the statement which I have marked below is true in relation to the
entity submitting this sworn statement. (Please indicate which statement applies.)
_____Neither the entity submitting this sworn statement, nor any of its officers, directors,
executives, partners, shareholders, employees, members, or agents who are active in management of
the entity, nor an affiliate of the entity has been charged with and convicted of a public entity crime
subsequent to September 1, 1990.
_____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 management of
the entity or an affiliate of the entity has been charged with and convicted of a public entity crime
subsequent to September 1, 1990.
_____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 management of
the entity or an affiliate of the entity has been charged with and convicted of a public entity crime
subsequent to September 1, 1990. 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 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 DIRECTOR OF
THE PURCHASING DEPARTMENT FOR THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 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 INFORMATION
CONTAINED IN THIS FORM.
(Signature)
Sworn to and subscribed before me this ____________ day of ______________20_____.
Personally known
OR Produced identification
Notary Public - State of
My commission expires
(Type of identification)
(Printed typed or stamped commissioned name of notary public)
Page 2 of 2
1
EXHIBIT B
THE SCHOOL DISTRICT OF PALM BEACH COUNTY
AFFIDAVIT OF TRUTH
The undersigned swears that the foregoing statements are true and correct and include all material
information necessary to identify and explain the operations of this firm as well as the ownership
thereof. Further, the undersigned agrees to provide complete and accurate information regarding
actual work performed on any projects, the payment therefore any proposed changes,
misrepresentation will be grounds for terminating any contract, which may be awarded, and
suspension or revocation of Prequalification certification.
Executed by: ____________________________
_______________________________________
Signature of Affiant
Sworn to and subscribed before me this ______ day of _____________20_____.
Personally known _____ OR Produced identification ___________________ (Type of identification)
Notary Public State of: ______________________
My Commission expires: _____________________
____________________________________________________
(Printed, typed or stamped commissioned name of notary public)
EXHIBIT C
REPLACE THIS PAGE WITH YOUR INSURANCE CERTIFICATE
SCHOOL DISTRICT OF PALM BEACH COUNTY
MINIMUM INSURANCE REQUIREMENTS FOR
PREQUALIFICATION OF CONSTRUCTION CONTRACTORS
APPLICATION REQUIREMENT
Applicants shall include a valid Certificate of Insurance (COI) with their Vendor Prequalification
Application as evidence of the minimum liability insurance coverages set forth below.
1. COMMERCIAL GENERAL LIABILITY (CGL): CGL Insurance including Contractual
Liability and products and completed Operations Insurance and shall be written on the
most recent form of CG 00 01 or its insurance carrier equivalent (with no exclusions for
subcontracted work).
a. Coverage shall be for Bodily and Personal Injury and Property Damages. Limits of
liability shall be set at One Million Dollars ($1,000,000.00) per occurrence. CGL
Insurance shall contain a general aggregate limit of Two Million Dollars
($2,000,000.00) and, it shall apply separately to the Project (per Project
aggregate) using the most recent form ISO CG2503 or the insurance carriers’
equivalent.
2. BUSINESS AUTOMOBILE LIABILITY: Motor vehicle liability shall be required with
limits of not less than One Million Dollars ($1,000,000.00) including per occurrence for
both Bodily Injury and Property Damage Combined Single Limit for owned, hired and non-
owned automobiles. This coverage shall be an “Any Auto” form policy. The insurance must
be an occurrence form policy. Business Auto Coverage shall be written on the most recent
form of ISO form CA 00 01 or equivalent liability coverage.
3. WORKERS COMPENSATION: In compliance with Chapter 440, Florida Statutes,
Employers’ Liability shall have minimum limits of:
a. $500,000 - Bodily Injury by Accident for each accident
b. $500,000 - Bodily Injury by Disease, policy limit
c. $500,000 - Bodily Injury by Disease, each employee
The Applicant’s Insurance Provider must meet the following minimum requirements: (1) Be
authorized by subsisting certificates of authority issued to the companies by the Department of
Insurance of the State of Florida or be eligible surplus lines insurers under Florida Statute
626.918; and (2) Must have a current rating of "A-" or better and a Financial Size Category of
"VIII" or better according to the most recent rating in effect by the A.M. Best Company.
PROJECT NAME:
ITB NO.: N/A PROJECT NO. N/A
Pursuant to School Board Policy 6.144 - Commercial Nondiscrimination and as part of its proposal, Bidder or
Proposer shall provide to the School District a list of all instances within the past ten (10) years where a complaint
was filed or pending against Bidder/Proposer in a legal or administrative proceeding alleging that Bidder or
Proposer discriminated on the basis of race, gender, gender identity or expression, religion, national origin,
ethnicity, sexual orientation, age, or disability against its subcontractors, vendors, suppliers, or commercial
customers, and a description of the status or resolution of each such complaint, including any remedial action
taken.
Please check the appropriate box:
I, the undersigned Authorized Representative for the Bidder/Proposer, certify that the Bidder/
Proposer has not, within the past ten (10) years from the proposal due date, had any instances
where a complaint was filed or pending against Bidder/Proposer in a legal or administrative
proceeding alleging that Bidder/Proposer discriminated on the basis of race, gender, gender
identity or expression, religion, national origin, ethnicity, sexual orientation, age, or disability
against its subcontractors, vendors, suppliers, or commercial customers.
The Bidder/Proposer, within the past ten (10) years from the Bid/Proposal due date, has had
instances where a complaint has been filed or has a pending complaint against it in a legal or
administrative proceeding alleging that the Bidder/Proposer discriminated on the basis of race,
gender, gender identity or expression, religion, national origin, ethnicity, sexual orientation, age,
or disability against one of its subcontractors, vendors, suppliers, or commercial customers.
The Bidder/Proposer must provide a detailed description of each discrimination complaint and the status
or resolution of each complaint, including any remedial action taken by the Bidder/Proposer.
Page 1 of 1
Revised 10/17/19
EXHIBIT D
THE SCHOOL DISTRICT OF PALM BEACH COUNTY
CONSTRUCTION PURCHASING DEPARTMENT
DISCLOSURE OF DISCRIMINATION COMPLAINTS STATEMENT
BIDDER (firm name):
SIGNATURE OF AUTHORIZED REPRESENTATIVE:
An original manual signature is required
PRINT NAME
& TITLE OF AUTHORIZED
REPRESENTATIVE:
VENDOR PREQUALIFICATION PROGRAM
PROJECT NAME:
ITB NO.: PROJECT NO.: _____________________
I certify that neither the Bidder nor its Principals are presently debarred, suspended, proposed
for debarment, declared ineligible or voluntarily excluded from participation in a procurement activity by
the State of Florida or any Federal Government agency.
The Bidder understands and agrees that should it be discovered to be in violation of, or fail to
disclose information regarding these clauses, it may be considered a material breach of the contract
and may result in contract termination, debarment, and other sanctions.
CONSTRUCTION PURCHASING DEPARTMENT
DISCLOSURE OF DISQUALIFYING CRIMES STATEMENT
EXHIBIT E
THE SCHOOL DISTRICT OF PALM BEACH COUNTY
CELL NO.:
BIDDER (Firm Name):
STREET ADDRESS:
CITY/STATE/ZIP
CONTACT PERSON
CONTACT PERSON'S ADDRESS:
TELEPHONE NO.:
EMAIL ADDRESS:
PROPOSER'S TAX PAYER IDENTIFICATION NUMBER:
NAME OF AUTHORIZED REPRESENTATIVE:
TITLE OF AUTHORIZED REPRESENTATIVE:
SIGNATURE OF AUTHORIZED REPRESENTATIVE:
DATE:
Page 1 of 1
Revised 10/17/2019
VENDOR PREQUALIFICATION PROGRAM
N/A
N/A
EXHIBIT F
The School Board of Palm Beach County
Attn: Construction Purchasing Department
3661 Interstate Park Rd. N., Suite 233
Riviera Beach, FL 33404
This is to advise that until further notice in writing to you, we agree to provide
suretyship on behalf of ______________________________ covering
construction in the amount of $___________________ for any single contract
and $ _________________ in the aggregate of outstanding contracts.
When more than one surety is included in this letter of intent, unless clearly
indicated to the contrary on this letter of intent, and separate limit indicated for
the surety on this letter of intent, each surety agrees that it shall be jointly and
severally liable with the other sureties included in this letter of intent.
Our Best Ratings for performance and size are:
PERFORMANCE RATING: ______
FINANCIAL SIZE: ________________________________________________
NAME OF SURETY: _______________________________________________
BY: _________________________________
Title
(Affix Seal)
SAMPLE LETTER
THIS IS A SAMPLE LETTER.
NOTE: VENDOR SHALL OBTAIN LETTER ON OFFICIAL
LETTERHEAD FROM SURETY/BONDING COMPANY WITH
REQUIRED INFORMATION AS SHOWN BELOW.
REPLACE THIS PAGE WITH LETTER FROM BONDING COMP
ANY
THE SCHOOL DISTRICT OF PALM BEACH COUNTY
Beneficial Interest and Disclosure of Ownership Affidavit
Project No./ Title
Corporate Name
Tax FEIN No.
Before me, the undersigned authority, personally appeared, , ("Corporate
Representative") this day of , 20 , who, first being duly sworn, as required by law,
subject to the penalties prescribed for perjury, deposes and says:
Corporate Representative has read the contents of this Affidavit, has actual knowledge of the facts contained
herein, and states that the facts contained herein are true, correct, and complete.
The following is a list of every "person" (as defined in Section 1.01(3), Florida Statues to include individuals,
children firms, associates, joint adventures, partnerships, estates, trusts, business trusts, syndicates,
fiduciaries, corporations and all other groups and combinations) holding 5% or more of the beneficial interest
in the disclosing entity: (If more space is needed, attach separate sheet)
1)
2)
A. Persons or corporate entities owning 5% or more:
B. Persons or corporate entities who hold by proxy the voting power of 5% or more:
C. Stock held for others and for whom held:
CORPORATE REPRESENTATIVE
SWORN TO
and subscribed before me this
Notary Public
(Print, Type or Stamp Name of Notary Public)
(NOTARY PUBLIC SEAL)
PBSD 1997 (Rev. 02/22/2011)
Bid No.
By:
day of
as identification.
, 20 , by
Such person(s) (Notary Public must check applicable box).
is/are personally known to me. produced a current driver license(s). produced
1.
2.
1.
2.
1.
2.
Name Address Percentage
Name Address Percentage
1. Name / 2. From Whom Held Address Percentage
EXHIBIT G
Page 1 of 1
N/A VENDOR PREQUALIFICATION PROGRAM
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THE SCHOOL DISTRICT OF PALM BEACH COUNTY, FLORIDA (School District of Indian River County)

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Completed 8 October 2021

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