facsimile transmission · 2016-05-11 · may. 9. 2016 12:55pm no.0887 p. 1 asplundhrailroaddivision...

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May. 9. 2016 12:55PM No. 0887 P. 1 ASPLUNDH RAILROAD DIVISION 708 Blair MillRoad Willow GroYe, PA19090 215.784.4285 FACSIMILE TRANSMISSION CES OFFERED: Weed & Brush Spraying. Tree & Brush Cutting' Pole Line Removel. Mowing. Herbicide Sales - Non-Chemical Weed Control DATE I 05/09/16 NUMBER OF PAGES (Including cover sheet) .13 o Urgent o ReplyASAP o Please Review o For your Records TO: DUSTY SMITH COMPANY: WI! DIVISION OF HIGHWAYS FAX NUMBER: 304.558.7844 PHONE NO.: 304.558.9398 FROM: DEBBY CONIGLIARO FAX NUMBER: 215.784.4334 PHONE NO. 215.784.4285 EMAIL ADDRESS:[email protected] COMMENTS: SOLICITATION NO. ARFQ 0804 RMA1600000007 Thanks very much Dusty! Remember" SAFElY' FIRST NO ONE GETS HURT" ::!l - ~ 0" JJ ::£ :z: ~ rn 0 m I 0 -\:; ~ 1.0 m -0 --;;; ~- ::It m W N 0 "'" .. ~ Con Con

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Page 1: FACSIMILE TRANSMISSION · 2016-05-11 · May. 9. 2016 12:55PM No.0887 P. 1 ASPLUNDHRAILROADDIVISION 708BlairMillRoad WillowGroYe,PA19090 215.784.4285 FACSIMILE TRANSMISSION CESOFFERED:

May. 9. 2016 12:55PM No. 0887 P. 1

ASPLUNDH RAILROAD DIVISION708 Blair Mill RoadWillow GroYe, PA 19090

215.784.4285

FACSIMILE TRANSMISSIONCES OFFERED: Weed & Brush Spraying. Tree & Brush Cutting' Pole Line Removel. Mowing.

Herbicide Sales - Non-Chemical Weed Control

DATE I 05/09/16

NUMBER OF PAGES (Including cover sheet) .13o Urgent

o ReplyASAP

o Please Review

o For your Records

TO: DUSTY SMITH

COMPANY: WI! DIVISION OF HIGHWAYS

FAX NUMBER: 304.558.7844

PHONE NO.: 304.558.9398

FROM: DEBBY CONIGLIARO

FAX NUMBER: 215.784.4334

PHONE NO. 215.784.4285

EMAIL ADDRESS:[email protected]

COMMENTS:SOLICITATION NO. ARFQ 0804 RMA1600000007

Thanks very much Dusty!

Remember" SAFElY' FIRST NO ONE GETS HURT"

::!l -~

0"JJ::£:z:

~ rn0mI 0-\:;

~

1.0 m-0

--;;;~-::It mW N 0"'"

..~

ConCon

Page 2: FACSIMILE TRANSMISSION · 2016-05-11 · May. 9. 2016 12:55PM No.0887 P. 1 ASPLUNDHRAILROADDIVISION 708BlairMillRoad WillowGroYe,PA19090 215.784.4285 FACSIMILE TRANSMISSION CESOFFERED:

May. 9. 2016 12:55PM No. 0887 P. 2

k\SPLUNDHIASPLUNDH TREEEXPERTCO.•RAILROAD DIVISION

720 COUNTY ROAD 400, IRONTON, OH 45638 - PHONE: 740.532.7035 - FAX: 740.532.2946

May 9, 2016

State of West VirginiaFinance & AdministrationDiv. of Highways, Bldg 5, RM A-2201900 Kanawha Blvd. ECharleston, WV 25302

Re: Solicitation No. ARFQ 0804 RMA1600000007

~ Cl"I

~ ::l: :JJ0 ::< ['T1iT> 0-\:, I::0 l.D m0 :~(") -0C :x:: m63 N Q2 ..

til-i til

The Asplundh Railroad Division appreciates the opportunity to submit aquotation for weed spraying on the South Branch Valley Railroad.

We would like to suggest the following language changes for item 35 of theGeneral Terms and Conditions: Change "from and against" to "to the extentcaused by" on line 2, By doing so, each party is responsible for their ownnegligence.

If you have any questions, or need additional information, please contactme at 215.784.4101,

Sincerely,.~«Randal L,HainesRegion Manager

RLH:dlc

Page 3: FACSIMILE TRANSMISSION · 2016-05-11 · May. 9. 2016 12:55PM No.0887 P. 1 ASPLUNDHRAILROADDIVISION 708BlairMillRoad WillowGroYe,PA19090 215.784.4285 FACSIMILE TRANSMISSION CESOFFERED:

May .. 9. 2016 12:55PM

Stale of West VirginiaRequest For Quotation

No. 0887 P. 3

Procurement Folder :205910

Documont Description: Weed spraying On the Soulh Branch Valley Railroad

Procurement Type : Agency Pu"",ase Order

Date Issued Solicitation Closes Solicitation No Vorsion Phase

:l016-04-:l5 :lOI IHlS.()9 ARFQ 0804 RMA 1600000007 1 Final

13:30:00

FINANCE & ADMINISTRATION

DIVISION OF HIGHWAYSBLDG 5, RM A.220

1.900 KANAWHA BLVD E

CHARLESTON

US25302

VendorN;

,. ~1IIII1IIPIIIl'CQ,p••••••••7084317)'(' Mill ~&.W) I/DtV G('()~e.,fA IqO'/D(:lI5) 7&1}- Lf:iD 1

FORM CD:W\I-PRC.ARF~'

FOR INFORMATION CONTACT THEDusty J Smith(304) [email protected] ,

Page: ,

DATE Ma 20 Ittl

Page 4: FACSIMILE TRANSMISSION · 2016-05-11 · May. 9. 2016 12:55PM No.0887 P. 1 ASPLUNDHRAILROADDIVISION 708BlairMillRoad WillowGroYe,PA19090 215.784.4285 FACSIMILE TRANSMISSION CESOFFERED:

May, 9, 2016 12:55PM No, 0887 P, 4

~C~o~m~m~O~d~'t'I~(C~o~d~e==iiiiiii~iiiiliL=======JM~o~d~e~,1i#=========:::JS~n.e~oi~fi~oa~t~io~n=========170141604

TotalPrice

VoN 26836

Unit PrioeUnitlsBU9EA

US

STATE RAIL AUTHORITY(DBA) SOUTH BRANCH VALLEY RAILROAD

120 WATER PLANT DR

MOOREfiELD

Q'"0,00000

WV26836

Commodil\fLineDesorlnllonProjectA- SpringWeedControl

Line1

US

STATE RAIL AUTHORITY120WATER PLANT OR

MOOREFIELD

Extended DescriptionSpringWoedoonlrolon theSouthBranchValleyRailroad

STATE RAIL AUTHORITY120WATER PLAN, DR

STATE RAIL AUTHORITY(DBA) SOUTH BRANCH VALLEY RAILROAD

120 WATER PLANT DR

MOOREFIELD WV26836 MOOREFIELD WV 26836

US US

Unu2

Commodiht Line DescrirdlonProjectB- FallWeedConlrol

Q'"0,00000

Unil'ssueEA

Unit Price Total Price

~c~o~m~m~o~d~li~ivc~o~d~e==M!iiiii~iiiiliL=======JMM;od~O~I1i#=========:::JS~ole~ci~fi~ca!il~io~n=========170141604

Extended DescriptionFallWeedconlrolonIhe SouthBranchValleyRailroad

D"h:lPrinted: Apr 2$, 20U; SolICitation Number: RMA1600D00001 FORM 10 : wv..pRC~FQ.oD'

Page 5: FACSIMILE TRANSMISSION · 2016-05-11 · May. 9. 2016 12:55PM No.0887 P. 1 ASPLUNDHRAILROADDIVISION 708BlairMillRoad WillowGroYe,PA19090 215.784.4285 FACSIMILE TRANSMISSION CESOFFERED:

May. 9. 2016 12:55PM No. 0887 P. 5

Document Phase Document DescriptiDn Page 3

RMA1600000007 final Weed spraying on the $OllIh Bran"" VOlley of3

Railroad

ADDmONAL TERMS AND CONDmONS

See attached document(s) for additional Tenns and Conditions

Page 6: FACSIMILE TRANSMISSION · 2016-05-11 · May. 9. 2016 12:55PM No.0887 P. 1 ASPLUNDHRAILROADDIVISION 708BlairMillRoad WillowGroYe,PA19090 215.784.4285 FACSIMILE TRANSMISSION CESOFFERED:

May. 9. 2016 12:55PM

RMA16B17 • Weed Spraying on SBVR

No. 0887 P. 6

Line

Item

Description

Weed Spraying on the S8VR

Project A.

Project B

Unit

Cost

Unit

of Measure

\

Quantity Extended

Cost

Page 7: FACSIMILE TRANSMISSION · 2016-05-11 · May. 9. 2016 12:55PM No.0887 P. 1 ASPLUNDHRAILROADDIVISION 708BlairMillRoad WillowGroYe,PA19090 215.784.4285 FACSIMILE TRANSMISSION CESOFFERED:

'ROJECT ACALCULATE MIXES LOAD CHECKER

""•••~~

>roduct Rete Cost Per Rate Acre. Ccst & Acre's Total Cost Talal Quantltv

azor 2.00 ot $1.50 $3.00 240.00luena\ 4'.000z $1.00 $4.00 480.00

~5D 3.000l. $7.20 $21.60 36D.00,ovderex 4.0002- $1.80 $7.20 480.00:ontrol wm 0.8D ot $0.80 $0.64 98.00

$36.04 120 $4372.8D

I.bor $5,.00.00tot.1 $9,772.8D

'ROJECT BCALCULATE MIXES

)radue' Rate Cost Per Rate Acre Cost a Acre,'s Total Cost Total Quantltv

'alor .0.00 I $1.30 $0.00 0.00trenite. 2.00 I.at $76.73 $1SJ.46 (lOO.DO~nlrol \11m D.80 0. $0.59 $0.47 160.0D

.'53.93 .20D $30,786.40

TCltill Lb.lGal. Train/Truck 1 Truck Z Total Check Dlf!

30 ~al. 0 •• 1. D •• I. 0 •• 1. 30 •• 1.4 •• 1. o •• 1. o "al. 0 •• 1. 4 "I.3 •• 1. o •• 1. 0 •• 1. 0 •• 1. 3 •• 1.

3D lb. o lb. D lb. o lb. 3D lb.

'''1. 0 •• 1. o •• 1. 0 •• 1. 1 1I!1I1.

LOAD CHECKERTotel Lb./Gat. Traln/fruck :J, Trude Z Total Cheek Dlf!

D -at. O~I. o ,.1. D "'al. o •• 1.400 •• 1 O~I. o ,.1. 0-.1. <lOCI•• 1.l ~a1. D~I. a "al 0--;;.1. 1 •• 1.

.....,=~.....,""""~""

lC!!bortotal

$5ADD.00$36,186.40

='"=0>0>

--'~

--'

Page 8: FACSIMILE TRANSMISSION · 2016-05-11 · May. 9. 2016 12:55PM No.0887 P. 1 ASPLUNDHRAILROADDIVISION 708BlairMillRoad WillowGroYe,PA19090 215.784.4285 FACSIMILE TRANSMISSION CESOFFERED:

May. 9. 2016 12:55PM.

CERTlFlCATIONAND SIGNATURE PAGE

No. 0887 P. 8

By signing below, or submitting documentation through wvOASIS, I certify that I have reviewedthis Solicitation in its entirety; that 1 understand the requirements, terms and conditions, andother information contained herein; that this bid, offer or proposal constitutes an offer to theState that cannot be unilaterally withdrawn; that the product or service proposed meets themandatory requirements contained in the Solicitation for that product or service, unlessotherwise stated herein; that the Vendor accepts the terms and conditions contained in theSolicitation, unless otherwise stated herein; that I am submitting this bid, offer or proposal forreview and consideration; that I am authorized by the vendor to ex:ecute and submit this bid,offer, or proposal, or any documents related therelo on vendor's behalf; that I am authorized tobind the vendor in a contractual relationship; and that to the best of my knowledge, the vendorhas properly registered with any State agency that may require registration.

ASPLUNDH TREE EXPERT CO., RAILROAD DIVISION

AANDAL L.. HAINES, REG.MGR.; 21S.784.4101, 215.'784.4334, MAya, 2016

(phone Number) (Fax Number) (Date)

Revised 10/27/2015

-.

Page 9: FACSIMILE TRANSMISSION · 2016-05-11 · May. 9. 2016 12:55PM No.0887 P. 1 ASPLUNDHRAILROADDIVISION 708BlairMillRoad WillowGroYe,PA19090 215.784.4285 FACSIMILE TRANSMISSION CESOFFERED:

May, 9, 2016 12:55PM No, 0887 P, 9

ADDITIONAL TERMS AND CONDITIONS (Construction Contracts Only)

1. CONTRACTOR'S LICENSE: West Virginia Code 9 21.11.2 requires that all personsdesiring to perform contracting work in this state be licensed. The West Virginia ContractorsLicensing Board is empowered to issue the contractor's license. Applications for a contractor'slicense may be made by contacting the West Virginia Division of Labor. West Virginia Code 921.11-11 requires any prospective Vendono include the contractor's license number on its bid.Failure to include a contractor's license number on the bid shall result in Vendor's bid beingdisqualified. Vendors should include a contractor's license number in the space provided below.

ASPLUNDH TREE EXPERT CO" RAILROAD DIVISIONContractor's Name: ---------------Contractor's License No.WV004458-------------

The apparent successful Vendor must furnish a copy of its contractor's license prior to theissuance of a Award Document.

2. DRUG-FREE WORKPLACE AFFIDAVIT: W. Va. Code 9 21.10-5 provides that anysolicitation for a public improvement contract requires each Vendor that submits a bid for thework to submit at the same time an affidavit that the Vendor has a written plan for a drugfreeworkplace policy. To comply with this law, Vendor must either complete the enclosed drug.freeworkplace affidavit and submit the same with its bid or complete a similar affidavit that fulfillsall of the requirements of the applicable code. FailUre to submit the signed and notarized drug-free workplace affidavit or a similar affidavit that fully complies with the requirements of theapplicable code, with the bid shall result in disqualification of Vendor's bid. Pursuant to W. Va.Code 21-1D-2(b) and (k), this provision does not apply to public improvement contracts thevalue of which is $100,000 or less or temporary or emergency repairs.

2.1. DRUG-FREE WORKPLACE POLICY: Pursuant to W. Va. Code 9 21.10-4, Vendor andits subcontractors must implement and maintain a written drug.free workplace policy thatcomplies with said article. The awarding public authority shall cancel this contract if: (1) Vendorfails to implement and maintain a written drug-free workplace policy described in the precedingparagraph, (2) Vendor fails to provide information regarding implementation of its drug.freeworkplace policy at the request of the public authority; or (3) Vendor provides to the publicauthority false information regarding the contractor's drug-free workplace policy.

Pursuant to W. Va. Code 21-lD-2(b) and (k), this provision does not apply to publicimprovement contracts the value of which is $100,000 or less or temporary or emergency repairs.

3. DRUG FREE WORKPLACE REPORT: Pursuant to W. Va. Code 9 21-1D-7b, no less thanonce per year, or upon completion of the project, every contractor shall provide a certified reportto the public authority which let the contract. For contracts over $25,000, the public authorityshall be the West Virginia Purchasing Division. For contracts of $25,000 or less, the publicauthority shall be the agency issuing the contract. The report shall include:(I) Information to show that the education and training service to the requirements of WestVirginia Code 9 21.ID-5 was provided;

Revised 10/27/2015

Page 10: FACSIMILE TRANSMISSION · 2016-05-11 · May. 9. 2016 12:55PM No.0887 P. 1 ASPLUNDHRAILROADDIVISION 708BlairMillRoad WillowGroYe,PA19090 215.784.4285 FACSIMILE TRANSMISSION CESOFFERED:

May. 9. 2016 12:56PM ." " , .................•.......... No, 0887 P. 10........•. ,.............. .' ", :

, ,

~'

::::"....

, .,.,;', .

Chflir. West Vuginia Contl:actotLirensiog Boon!

Expiration Date

~PLUNDH TREE EXPERT COPBA ASPLUNDH TREE EXPERT CO708 llLAIR MILL RDWILWW GROVE, PA 19090

WV004458

CONTRACTOR LICENSE

~.

West Virginia Contractor Licensing BoardAuthorized by the

,"

",:., ..

Date Issued

'nilS' ~ or a copy Ibtrwx&f,most bt pMUd JQ ~ u.m:plcuolDI place at t'lfrt:rj cOD£bilC:tioa sitt wbtrt work IBbeingptda...-d. Tills IittD5e DumberllUUt •.•pptat' In aD ad,~dftmeDl!1ODan bia. rmbmis5iu. bd 0:0.an fun,) tlCetulfA0lUlblDdlDg •• ntrad5. Tbi< 6••••••••••• ~•••• lgDelIor ~ b, _ bed •••d•• pro'risi •••• tWos'VfrEiDla Codr., Chapter 21, Artide U.

. '.' '. :",,'.;" NI:l~~!i:R'22 .• :ZOl5~:"

SPECIALTY

Classification:

Number:

WEST VIRGINIACONTRACTORLICENSING) BOARD,

Page 11: FACSIMILE TRANSMISSION · 2016-05-11 · May. 9. 2016 12:55PM No.0887 P. 1 ASPLUNDHRAILROADDIVISION 708BlairMillRoad WillowGroYe,PA19090 215.784.4285 FACSIMILE TRANSMISSION CESOFFERED:

May. 9. 2016 12:56PM No. 0887 P. 11

ADDENDUM ACKNOWLEDGEMENT FORMSOlICITATION NO.:

Instructions: Please acknowledge receipt of all addenda issued with this solicitation bycompleting this addelldum acknowledgment form. Check the box next to each addendumreceived and sign below. Failure to acknowledge addenda may result in bid disqualification.Acknowledgment: I hereby acknowledge receipt of the following addenda and have made thenecessary revisions to my proposal, plans and/or specification, etc.

Addendum Numbers Received:(Check the box next to each addendum received)

.0Addendum NO.1

oAddendum NO.2

o Addendum NO.3

o Addendum NO.4

o Addendum NO.5

o Addendum NO.6

o Addendum NO.7

o Addendum NO.8

oAddelldum NO.9

oAddendum No. 10

I understand that failure to confirm the receipt of addenda may be cause for rejection of this bid.I further understand that any verbal representation made or assumed to be made during any oraldiscussion held between Vendor's representatives and any state personnel is not binding. Onlythe information issued in writing and added to the specifications by an official addendum isbinding.ASPLUNDH TREE EXPERT CO., RAilROAD DIVISION

Company ~

"..-'.'~ ..,.~ ~AulliorizRANDAL L. HAINES, REG. MGR.; MAY 9,2016

Date

NOTE: This addendum acknowledgement should be submitted with the bid to expeditedocument processing.

Revised 10/27/2015

Page 12: FACSIMILE TRANSMISSION · 2016-05-11 · May. 9. 2016 12:55PM No.0887 P. 1 ASPLUNDHRAILROADDIVISION 708BlairMillRoad WillowGroYe,PA19090 215.784.4285 FACSIMILE TRANSMISSION CESOFFERED:

May. 9. 2016 12:56PM

STATE OF WEST VIRGINIAPurchasing Division

PURCHASING AFFIDAVIT

No. 0887 P. 12

MANDATE: Under W. Va. Code ~5A-3-10a, no conlract or renewal of any contract may be awarded by the state or anyof its political subdivisions to any vendor or prospective vendor when the vendor or prospective vendor or a related partyto the vendor or prospective vendor is a debtor and: (1) Ihe debl owed is an amount greater lhan one thousand dollars inthe aggregate; or (2) the debtor is in employer delault.

EXCEPTION: The prohibition listed above does not apply where a vendor has contested any tax administered pursuanllochapter eleven of the W. Va. Code, workers' compensation premium, perm~ fee or environmental fee or assessment andthe maner has not become final or where the vendor has entered into a payment plan or agreement and the vendor is nolin default of any of the provisions of such plan or agreement.

DERNITIONS:

"Debt" means any assessment, premium, penally, fine, tal<or other amount of money owed to the state or any of itspolitical subdivisions because of a judgment, line, permit violation, license assessment, defaulted workers'compensation premium, penalty or other assessment presently delinquent or due and required to be paid 10 the staleor any of its political subdivisions, including any interest or additional penalties accrued thereon.

"Employer default" means having an oulstanding balance or liability 10 the old tund or to the uninsured employers'fund or being in policy default, as defined in W. Va. Code ~ 23-2c-2, failure to maintain mandatory workers'compensation coverage, or failure to fully meel its obligations as a workers' compensation self-insured employer. Anemployer is not in employer default if it has entered into a repayment agreement with !he Insurance Commissionerand remains in compliance ~h the obligations under the repayment agreement.

"Related party" means a party, whether an individual, corporation. partnership, association, limited liability companyor any other form or business association or other entity whatsoever, related to any vendor by blood, marriage,ownership or contract through which the party has a relationship of ownership or other interest with the vendor so thatthe party will actually or by effecl receive or control a portion of the benefit, profit or other consideration fromperformance of a vendor contract with the party receiving an amounl that meets or exceed five percent of the totalcontract amount.

AFRRMATION: By signing this form, the vendor's authorized signer affirms and acknowledges under penalty oflaw for false swearing (w. Va. Code ~61.5-3) that neither vendor nor any related party owe a debt as definedabove and that neither vendor nor any related party are in employer default as defined above, unless the debt oremployer default is permitted under the exception above.

WITNESS THE FOLLOWING SIGNATURE:

Vendor's Name: ASPLUNDH ...f'

Authorized Signature:,i(

AILROAD DIVISION

Date: MAY 9, 2016

Slaleof PENNSYLVANIA

Countyof MONTGOMERY, to-wit:

Taken, subscribed, and sworn to before mr~i:~day of_M_A_Y ..20 16.

My Commission expires----:t:t£5 '20\10AFFIX SEAL HERE

COMMO W 05 ~KHNSVLVANIA

NOTARIAL SEALDORA L.NEWMAN, NolaryPubficHorshamTWP .• MontgomeryCountyMyCommission iresJu 25,2016

Page 13: FACSIMILE TRANSMISSION · 2016-05-11 · May. 9. 2016 12:55PM No.0887 P. 1 ASPLUNDHRAILROADDIVISION 708BlairMillRoad WillowGroYe,PA19090 215.784.4285 FACSIMILE TRANSMISSION CESOFFERED:

May. 9. 2016 12:56PM No. 0887

WV.10Apptoved I Revised12/16115

N/AState of West Virginia

VENDOR PREFERENCE CERTIFICATE

P. 13

5igned: _

7.

b

6.o

Certilicalion and application is hereby made for Preference in accordance with Wesl Virginia Code, ~5A.3-37. (Does not apply toconstruction contraets). West Virginia Code, ~A.3-37, provides an opportunity for qual~ying vendors 10request (at the time of bid)preference for their residency status. Such preference is an evaluation method only and will be applied only to the cost bid inaccordance with the Wesl VIrginia Code. This certificate for application is to be used 10request such preference. The PurchasingDivision will make the determination of the Vendor Preference, if applicable.1. Application is made for 2.5% vendor preference for the reason checked:o Bidder is an individual resident vendor and has resided continuously in West Virginia forfour (4) years immediately preced-

ing the date of this certification: or,o Bidder is a partnership, association or corporation resident vendor and has maintained its headquarters or principal place ofbusiness continuously in West Virginia lor four (4) years immediately preceding the date of this certification:

o Bidder is a resident vendor partnership, association, or corporation with at least eighty percent of ownership interestof bidder held by another entity that meets the applicable four year residency requirement; or,

o Bidder is a nonresident vendor which has an affiliate or subsidiary which employs a minimum alone hundred state residemsand which has maintained its headquarters or principal place of business within West Virginia continuously for the four (4)years immediately preceding the date of this cert~icalion; or,

Application Is made for 2.5% vendor preference for the reason checked:Bidder is a resident vendor who certifies that, during the life of the contract, on average at least 75% of the employeesworking on the project being bid are residents of West Virginia who have resided in the state continuously for the two yearsimmediately preceding submission of this bid; or,

Application is made for 2.5% vendor preference for the reason checked:Bidder is a nonresident vendorthat employs a minimum alone hundred state residents, or a nonresident vendor whichhas an affiliate or subsidiary which maintains its headquarters or principal ptace of business within Wesl Virginia andemploys a minimum of one hundred state residents, and for purposes of producing or distribu~ng the commodities orcompleting the project which is the subject of the bidder's bid and continuously over the endre term of the project, onaverage at least seventy-five percent of the bidder's employees orlhe bidder's affiliate's or subsidiary's employees areresidenls of West Virginia who have resided in the stale continuously for the two immediately preceding years and Ihevendor's bid: or,

Application Is made tor 5% vendor preference for the reason checked:Bidder meets either the requirement of both subdivisions (1) and (2) or subdivision (1) and (3) as stated above; or,

Application is made for 3,5% vendor preference who is a veteran for the reason checked:Bidder is an individual resident vendor who is a veteran 01the United States armed forces, the reserves orthe Nalional Guardand has resided in West Virginia con~nuously for the four years immediately preceding the date on which the bid issubmitled; or,

Application Is made tor 3.5% vendor preference who is a veteran for the reason checked:Bidder is a resident vendor who is a veteran 01the United States armed forces, the reserves or the National Guard, ii, forpurposes of producing or distributing the commodities or completing the project which is the subject olthe vendor's bid andcontinuously over the entire term of the project, on average at least seventY-five percent of the vendor's employees areresidents of West Virginia who have resided in the state continuously for the two immediately preceding years,

Application is made for preference as a non-resident small, women. and minority.owned business, in accor.dance with West VIrginIa Code !j5A-3-59 and West Virginia Code of Slale Rules.o .Bidder has been or expects to be approved prior to contract award by the Purchasing DMsion as a ce~ied small, women.and minority-owned business.

Bidder understands ~ the Secretary of Revenue determines that a Bidder receiving preference has failed 10continue to meet therequirements for such preference. the Secretary may order the Director of Purchasing to: (a) rescind the contractor purchase order;or (b) assess a penalty against such Bidder in an amount nolto exceed 5% of the bid amount and thaI such penalty will be paid tothe contracting agency or deducted from any unpaid balance on the contract or purchase order.

By submission of this certificate, Bidder agrees to disclose any reasonably requested information 10(he PurChasing Division andauthorizes the Department 01Revenue to disclose to the Director of Purchasing appropriate information verifying thai Bidder has paidthe required business taxes, provided that such informadon does not contain the amounts 01taxes paid nor any other informationdeemed by the Tax Commissioner to be confidential.

Bidder hereby certifies that this certificate is 'rue and accurate in all respects; and thet I'a contract is issued to Bidderand if anything contained within this certificate changes during the term of the contract, Bidder wlll notitythe Purchas-Ing Division in writing immediately.

Bidder: _

4.ob

Date: MAYll,201& . TIUe: _

.Ch9ck any combination of preference com;ideration(s) indicared above, which you are entitled 10 tece;ve.