sharyland independent school district · san juanita (janie) cruz - member ben clinton “it all...

Raymondville Independent School District 419 FM 3168, Raymondville, Texas 78580

http://www.raymondvilleisd.org Phone: (956) 689-8175

Fax: (956) 689-8180

Board of Trustees Administration John L. Solis III - President Stetson Roane

Javier Longoria - Vice Pres. Superintendent

Adrian J. Montemayor - Secretary Andrea Mungia

Judy Gutierrez - Asst. Sec. Curriculum & Instruction Director

Mario Tijerina - Member David Longoria

Pedro Soria - Member Chief Financial Officer

San Juanita (Janie) Cruz - Member Ben Clinton “It All Stars Here!” Assistant Superintendent

Instruction to Bidder RFP NUMBER: 20-007 OPENING DATE: September 23, 2019 RFP FOR: Portable X-Ray Machine and X-Ray Simulator Proposals are solicited for furnishing the merchandise, supplies, services and/or equipment set forth in this proposal. Complete proposal documents will be accepted until 3:00 p.m., on the above specified date shown above at which time they will be opened in the Board Room at the Raymondville School District, 419 FM 3168, Raymondville, Texas 78580. LATE proposals will be returned unopened to the Bidder. Bidders are invited to be present at the proposal opening. PLEASE MARK THE FRONT OF ENVELOPE WITH RFP# 20-007 Portable X-Ray Machine and X-Ray Simulator. Proposals may be withdrawn at any time prior to the official opening. Alterations made before opening time must be initialed by bidder guaranteeing authenticity. After the official opening, proposals may not be amended, altered, or withdrawn. The undersigned agrees, if this proposal is accepted, to furnish any and all items upon the terms and conditions contained in the specifications. If the bidder fails to follow proposal specifications then the Uniform Commercial Code will govern. The period for acceptance of this proposal will be sixty (60) calendar days unless bidder inserts a different period. Please note the attached conditions of the proposal. All proposals must be submitted on proposal sheets provided and in accordance with specifications and descriptions on the proposal sheets. Proposals may be submitted on any/or all items, unless stated otherwise. The district reserves the right to accept or reject in part or in whole any proposal submitted, to waive any technicalities, and to award the proposal in the best interest of the district. All questions relating to specifications must be in writing to: Purchasing Department [email protected] Fax: (956) 689-8187 THE VENDOR ACKNOWLEDGMENT FORM MUST BE SIGNED. FAILURE TO SIGN FORM WILL RESULT IN

REJECTION OF PROPOSAL AND REMOVAL OF VENDOR FROM APPROVED VENDOR LIST FOR THE TIME SUCH PROPOSAL IS IN FORCE.

RISD does not discriminate on basis of race, color, national origin, sex, religion,

age or disability in employment or provision of services, programs or activities

mailto:[email protected]

RAYMONDVILLE INDEPENDENT SCHOOL DISTRICT

RFP# 20-007 PORTABLE X-RAY MACHINE and X-RAY SIMULATOR

VENDOR ACKNOWLEDGEMENT FORM

IN ORDER FOR YOUR PROPOSAL TO BE CONSIDERED IN THE PROPOSAL PROCESS, THE FOLLOWING ITEMS ARE REQUIRED TO BE INCLUDED IN THE PROPOSAL PACKAGE: Checklist: Yes No 1. STANDARD TERMS AND CONDITIONS 2. GENERAL TERMS AND CONDITIONS

3. FELONY CONVICTION NOTIFICATION 4. CONFLICT OF INTEREST QUESTIONNAIRE ________ ________ 5. RISD CRIMINAL HISTORY RECORDS INFO. REQUEST ________ ________ 6. DPS COMPUTERIZED CRIMINAL HISTORY VERIFICATION ________ ________ 7. PROPOSAL SPECIFICATION REQUIREMENT FORM 8. REFERENCE SHEET 9. NON-COLLUSION STATEMENT & SIGNATURE EVEN IF NOT SUBMITTING A PROPOSAL ON ALL ITEMS 10. W-9 FORM 11. SCOPE OF PROJECT 12. CERTIFICATE OF INTERESTED PARTIES FORM 1295 ________ ________ 13. PROPOSAL FORMS pertaining to this proposal should have ALL lines filled in as needed: 14. CERTIFICATION REGARDING TERRORIST ________ ________

Company Name: ______________________________________________ Address: ____________________________________________________ City, State: ______________________________Zip Code: ____________ Phone Number: _________________ Fax Number: _________________ Authorized Signature: __________________________________________ Bidder (Print Name): ___________________________________________ Official Position with Company: _________________________________

*****THE VENDOR ACKNOWLEDGEMENT FORM MUST BE SIGNED. FAILURE TO SIGN FORM WILL

RESULT IN REJECTION OF PROPOSAL AND REMOVAL OF VENDOR FROM APPROVED VENDOR LIST FOR THE TIME SUCH PROPOSAL IS IN FORCE*****

RAYMONDVILLE INDEPENDENT SCHOOL DISTRICT (956) 689-8175 419 FM 3168, Raymondville TX 78580


STANDARD TERMS AND CONDITIONS

The words “bids, proposals, quotes” and their derivatives may be used interchangeably in these terms and conditions are applicable on all bids, requests for proposals, quotes, competitive sealed quotes, etc. to which they are attached. 1. SELLER OF PACKAGE GOODS: Seller will package goods in accordance with good commercial practice. Each

shipping Container shall be clearly and permanently packed as follows: (a) Seller's name and address; (b) Consignee's name, address and purchase order number; (c) Container number and total number of containers e.g. box 1 of 4 boxes; and (d) the number of the container bearing the packing slip. Seller shall bear cost of packing unless otherwise provided. Goods shall be suitable packed as to secure the lowest transportation costs and to conform with requirements of common carriers and any other specifications. Buyer's count or weight shall be final and conclusive on shipment not accompanied by packing list.

2. SHIPMENT UNDER RESERVATION PROHIBITED: Seller is not authorized to ship the goods under reservation

and no tender of a bill of lading will operate as tender of goods.

3. TITLE AND RISK OF LOSS: Title and risk of loss of the goods shall not pass to Buyer until Buyer actually receives and

takes possession of the goods at the point.

4. DELIVERY TERMS AND TRANSPORTATION CHARGES: F.O.B. Destination Freight Prepaid unless delivery

terms are specified otherwise in bid: Buyer agrees to reimburse Seller for transportation costs in the amount specified in Seller's bid, or actual costs, whichever is lower, if the quoted delivery terms do not include transportation costs, provided Buyer shall have the right to designate what method of transportation shall be used to ship the goods.

5. NO PLACEMENT OF DEFECTIVE TENDER: Every tender of delivery of goods must fully comply with all provisions

of this contract as to time of delivery, quality and the like. If a tender is made which does not fully conform, this shall constitute a breach and Seller shall not have the right to substitute a conforming tender provided, where the time for performance has not yet expired, the Seller may seasonable notify Buyer of his intention to cure and may then make a conforming tender within the contract time but not afterward.

6. PLACE OF DELIVERY: The place of delivery shall be that set forth on the purchase order. Any change thereto shall be

effected by modification as provided for in Clause 20, "Modification", hereof. The terms of this agreement are "no arrival, no sale"

7. INVOICES AND PAYMENT:

a. Seller shall submit separate invoices, in duplicate, on each purchase order after each delivery. Invoices shall indicate the purchase order number, shall be itemized and transportation charges, if any, shall be listed separately. A copy of the bill of lading, and the freight weigh bill when applicable should be attached to the invoice. Mail to: Raymondville I.S.D. Accounts Payable, 419 FM 3168, Raymondville, TX 78580. Payment shall not be due until the above instruments are submitted after delivery. Suppliers should keep the Accounts Payable department advised of any changes in your remittance addresses.

b. Buyer's obligation is payable only and solely from funds available for the purpose of the purchase. Lack of funds shall render this contract null and void to the extent funds are not available and any delivered but unpaid for goods will be returned to Seller by Buyer.

c. Do not include Federal Excise, State or city Sales Tax. R.I.S.D. shall furnish tax exemption certificate, if requested.

8. GRATUITIES: The buyer may, by written notice to the Seller, cancel this contract without liability to Seller if it is determined by

Buyer that gratuities were offered or given by the Seller, or any agent, or representative of the Seller, to any officer or employee of the Raymondville I.S.D. with a view toward securing a contract or securing favorable treatment with respect to the awarding or amending or the making or any determinations with respect to the performing of such contract. In the event this contract is canceled by Buyer pursuant to this provision. Buyer shall be entitled, in addition to any other rights and remedies, to recover or withhold the amount of the cost incurred by Seller in providing such gratuities.

9. SPECIAL TOOLS AND TEST EQUIPMENT: If the price stated on the face hereof includes the cost of any special test

equipment fabricated or required by Seller for the purpose of filling this order, such special tooling equipment and any process sheets related thereto shall become the property of the Buyer and to the extent feasible shall be identified by the seller as such.

RAYMONDVILLE INDEPENDENT SCHOOL DISTRICT (956) 689-8175 419 FM 3168, RAYMONDVILLE, TX 78580



10. WARRANTY PRICE:

a. The price to be paid by the buyer shall be that contained in Seller's bid which Seller warrants to be no higher than Seller's current prices on orders by other products of like kind and specification covered by this agreement for similar quantities under similar or like conditions and methods of purchase. In the event Seller breaches this warranty, the prices of the items shall be reduced to the Seller's current prices on orders by others, or in the alternative, Buyer may cancel this contract without liability to Seller for breach or Seller's actual expense.

b. The Seller warrants that no person or selling agency has been employed or retained to solicit this contract upon an agreement or understanding for commission, percentage, brokerage or contingent fee excepting bona fide employees of bona fide established commercial or selling agencies maintained by the Seller for the purpose of securing business. For the breach or violation of this warranty, the Buyer shall have the right in addition to any other right or rights to cancel this contract without liability and to deduct from the contract price, or otherwise recover the full amount of such commission, percentage, brokerage or contingent fee.

11. WARRANTY PRODUCTS: Seller shall not limit or exclude any implied warranties and any attempt to do so shall render this

contract voidable at the option of the Buyer. Seller warrants that the good furnished will conform to the specifications, drawings and descriptions listed in the bid invitation and to the sample(s) furnished by Seller, if any. In the event of a conflict between the specifications, drawing and descriptions, the specifications shall govern.

12. SAFETY WARRANTY: Seller warrants that the product sold to Buyer shall conform to the standards promulgated by the U.S.

Department of Labor under the Occupational Safety and Health Act of 1970. In the event the product does not conform to OSHA standards, Buyer may return the product for correction or replacement at the Seller's expense. In the event Seller fails to make appropriate correction within a reasonable time or 30 days whichever is shorter, correction may be made by the buyer at Seller's expense.

13. NO WARRANTY BY BUYER AGAINST INFRINGEMENTS: As part of this contract for sale Seller agrees to

ascertain whether goods manufactured in accordance with the specifications attached to this agreement will give rise to the rightful claim of an third person by way of infringement or the like. Buyer makes no warranty that the production of goods according to the specification will not give rise to such a claim, and in no event shall Buyer be liable to seller for indemnification in the event that seller is sued on the grounds of infringement or the like. If seller is of the opinion that an infringement or the like will result, he will notify Buyer to this effect in writing within two weeks after the signing of the agreement. If Buyer does not receive notice and is subsequently held liable for the infringement or the like, Seller will save Buyer harmless. If Seller in good faith ascertains that production of the goods in accordance with specifications will result in infringement or the like, this contract shall be null and void except that Buyer will pay Seller the reasonable cost of his search as to infringements.

14. RIGHT OF INSPECTION: Buyer shall have the right to inspect the goods at delivery before accepting them. 15. CANCELLATION: Buyer shall have the right to cancel for default all or any part of the undelivered portion of this order if Seller

breaches any of the terms hereof including warranties of Seller or if the Seller becomes insolvent or commits acts of bankruptcy. Such right of cancellation is in addition to any not in lieu of any other remedies, which Buyer may have in law or equity.

16. TERMINATION: The performance of work under this order may be terminated in whole or in part by the Buyer in accordance

with this provision. Termination of work here-under shall be effected by the delivery to the Seller of a "Notice of Termination" specifying the extent to which performance of work under the order is terminated and the date upon which such termination becomes effective. Such right of termination is in addition to and not in lieu of rights of Buyer set forth in Clause 15, herein.

17. FORCE MAJEURE: If by reason of Force Majeure, either party hereto shall be rendered unable wholly or in part to carry out its

obligations under this agreement then such party shall give notice and full particulars of Force Majeure in writing to the other part within a reasonable time after occurrence of the event or cause relied upon, and the obligation of the party giving such notice, so far as it is affected by such Force Majeure, shall be suspended during the continuance of the inability then claimed, except as herein provided, but for not longer period, and such party shall endeavor to remove or overcome such inability with all reasonable dispatch. The term Force Majeure as employed herein, shall mean acts of God, strikes, lockout, or other industrial disturbances, act of public enemy, orders of any kind of government of the United States or the State of Texas or an civil or military authority, insurrections, riots, epidemics, arrests, restraint of government and people, civil disturbances, explosions, act of war, or any other causes not reasonable in the control of the party claiming such inability.

18. ASSIGNMENT DELEGATION: No right or interest in this contract shall be assigned or delegation of any obligation made

by Seller without the written permission of the Buyer. Any attempted assignment or delegation by Seller shall be wholly void and totally ineffective for all purposes unless made in conformity with this paragraph.

19. WAIVER: No claim or right arising out of a breach of this contract can be discharged in whole or in part by waiver or renunciation of

the claim or right unless the waiver or renunciation is supported by consideration and is in writing signed by the aggrieved.




20. MODIFICATIONS: This contract can be modified or rescinded only by a writing signed by both parties or their duly authorized

agents.

21. INTERPRETATION PAROLE EVIDENCE: This writing is intended by the parties as a final expression of their

agreement and is intended also as a complete and exclusive statement of the terms of their agreement. No course of prior dealings between the parties and no usage of the trade shall be relevant to supplement or explain any term used in this agreement. Acceptance or acquiescence in a course of performance rendered under this agreement shall not relevant to determine the meaning of this agreement even though the accepting or acquiescing party has knowledge of the performance and opportunity for objection. Whenever a term defined by the Uniform Commercial Code is used in this agreement, the definition contained in the code is to control.

22. APPLICABLE LAW: This agreement shall be governed by the Uniform Commercial Code. Wherever the term "Uniform

Commercial Code" is used, it shall be construed as meaning the Uniform Commercial Code as adopted in the State of Texas as effective and in force on the date of the agreement.

23. ADVERTISING: Seller shall not advertise or publish, without Buyer's prior consent, the fact that Buyer has entered into this

contract except to the extent necessary to comply with proper requests for information from an authorized representative of the federal, state or local government.

24. RIGHT TO ASSURANCE: Whenever one party to this contract in good faith has reason to question the other party's intent to

perform he may demand that the other give written assurance of his intent to perform. In the event that a demand is made and no assurance is given with (5) days, the demanding party may treat this failure as an anticipatory repudiation of the contract.

25. VENUE: Both parties agree that venue for a litigation arising from this contract shall be in Willacy County, Texas

26. PROHIBITION AGAINST PERSONAL INTEREST IN CONTRACTS: Any board member which has any

substantial interest, either direct or indirect, in any business entity seeking to contract with the District, shall, before any vote or decision on any matter involving the business entity, file an affidavit stating the nature and extent of interest and shall the business entity, file an affidavit stating the nature and extent of interest and shall abstain from any participation in the matter. This is not required if the vote or decision will not have any special effect on the entity other than its effect on the public. However, if a majority of the governing body are also required to file, and do file similar affidavits, then the member is not required to abstain from further participat ion. Vernon’s Texas Codes Annotated, Local Government Code, Chapter 171.

27. OVERATGES: Vendor hereby assigns to purchaser any and all claims for overages associated with this contract which arise

under the antitrust laws of the United States, 15 USCA Section 1 et. seq., and which arise under the antitrust laws of the State of Texas, Tex Bus. and Com. Code, Section 15.01, et. seq.

28. COMMUNICATION WITH EVALUATION TEAM MEMBERS: Vendor(s) submitting proposals shall not discuss

this RFP with employees of the RISD or members of the Board of Trustees. The only discussion allowed will be at the scheduled interview, if held, if your company is selected for an interview. Failure to abide by this requirement may result in disqualification.



GENERAL TERMS AND CONDITIONS

The words “bids, proposals, quotes” and their derivatives may be used interchangeably in these terms and conditions are applicable on all bids, requests for proposals, quotes, competitive sealed quotes, etc. to which they are attached. The Raymondville Independent School District is requesting proposal on merchandise, supplies, and/or equipment set forth in the proposal, vendors certify that:

1. Proposals are to be mailed or delivered to:

Andres Villalpando, Coordinator for Purchasing Raymondville Independent School District 419 FM 3168 RAYMONDVILLE, TX 78580

All questions relating to specifications must be in writing to:

Andres Villalpando, Coordinator for Purchasing [email protected] Fax: (956) 689-8180 Please check the website daily for addendums, and questions and answers posted.

2. All delivery charges - freight, inside delivery, installation, are included in proposal prices. Delivery will be F.O.B. Destination.

3. Faxed proposals will not be accepted.

4. Samples may be requested for testing by the district. Samples that fail testing shall be sufficient reason to reject a proposal or bid item.

Samples not submitted upon request will be sufficient reason to reject a proposal or proposal item.

5. Continuing non-performance of the bidder in terms of specifications shall be a basis for the termination of the contract bid. Cancellation

by the district may be made upon thirty (30)-calendar days written notice to the successful vendor. The district SHALL NOT PAY for work, equipment, or supplies, which are unsatisfactory. Vendors will be given a reasonable opportunity (30 calendar days) before termination, to correct the deficiencies. This, however, shall in no way be construed as negating the basis for termination for non-performance.

6. Sums of money shall be indicated both by unit cost and total item cost. In case of discrepancy, the unit cost shall govern.

7. The proposal award shall be based on, but not necessarily limited to the following factors: Maximum Points (a) The purchase price unit price 50 (b) The reputation of the vendor’s goods and services 10 (c) The quality of the vendor’s goods and services 10 (d) The extent to which the goods or services meet the district’s needs 10 (e) The vendor’s past relationship with district 5 (f) The impact of the ability of the district to comply with laws and vendor’s 5 relating to historically underutilized business (g) The total long-term cost to the district to acquire the vendor’s 5 goods and services (h) Any other relevant factors that a private business entity would consider 5 in selecting a vendor 100

8. Each and every deviation from the Specifications or the General conditions must be itemized on the Deviations Form. In the event

there are no deviations from either the Specifications or the General Conditions, an entry must be made on the Deviations Form stating "No Deviations". This form is an integral and required part of the official proposal of each company.

mailto:[email protected]



GENERAL TERMS AND CONDITIONS

9. Whenever an article or material is defined by describing a proprietary product or by using the name of a manufacturer or brand name,

the term "OR EQUAL" if not inserted SHALL BE IMPLIED. The specified article or material shall be understood as indicating the type, function, minimum standard of design, efficiency and quality desired and shall not be construed as to exclude other manufactured products of comparable quality, design and efficiency. "OR EQUAL" INTERPRETATION CLAUSE: Any time a particular manufacturer's name or brand is specified, it shall mean any product of equal or superior quality. Proposals shall be considered on all other brands submitted of equal or superior quality. On such bid items the bidder shall indicate clearly the product on which he is proposing, and shall supply sufficient data on brand or manufacturer specified. When more than one brand name of the "or equal" is available, do not propose more than two items choices. THE DISTRICT RESERVES THE RIGHT TO FINAL DECISION OF ANY PRODUCT STATED TO BE OF EQUAL OR SUPERIOR QUALITY.

10. The district reserves the right to make final decisions as comparable items. Be very certain that items upon which you proposal and

deliver are equal to items listed. Materials, which are not equal, shall be returned to the vendor transportation charges collect.

11. Patented or Copyright Protected Items:

The fact that a particular item is covered by a patent or copyright does not automatically mean that the purchase falls under the provisions pertaining to exemptions from the competitive bidding requirements for items available from only one source. In fact, patents cover nearly all consumer goods. To be a bona fide exemption to the competitive proposing requirement, there must be no other like items available for purchase that would serve the same purpose or function, and only one price for the product because of exclusive distribution or marketing rights. In the event any article to be sold or delivered hereunder is covered by any patent, copyright, trademark, or application thereof, the seller shall indemnify and hold harmless the district from any and all loss, cost, expenses and legal fees on account of manufacture, sale, or use of such article in violation of infringement or the like of rights under such patent, copyright, trademark or application.

12. During the performance of this contract, the vendor agrees not to discriminate against any employee or applicant for employment

because of race, color, national origin, age, religion, gender, marital or veteran status, or handicapping condition.

13. All contracts and agreements between merchants and the Raymondville I.S.D. shall strictly adhere to the statutes as set forth in the

Uniform Commercial Code as last amended in 1990 by the American Law Institute in the National Conference of Commissioners on Uniform State Laws. Reference: Uniform Commercial Code, 1990 official text.

14. Merchandise received shall be new merchandise, not used, or shop worn merchandise. Merchandise received in this condition will be

returned freight collect at the vendor’s expense. If this problem is not corrected within ten (10) working days of notification, then Raymondville I.S.D. under the Uniform Commercial Code will have the right to exercise the right to remedy.

15. Any change to original proposal documents must be in a written addendum and signed by Purchasing Agent or designee.



FELONY CONVICTION NOTIFICATION

State of Texas Legislative Senate Bill No. 1, Section 44.034, Notification of Criminal History, Subsection (a) states “a person or business entity that enters into a contract with a school district must give advance notice to the district if the person or an owner or operator of the business entity has been convicted of a felony. The notice must include a general description of the conduct resulting in the conviction of a felony.” Subsection (b) states “a school district may terminate a contract with a person or business entity if the district determines that the person or business entity failed to give notice as required by Subsection (a) or misrepresented the conduct resulting in the conviction. The district must compensate the person or business entity for services performed before the termination of the contract.”

I, the undersigned agent for the firm named below, certify that the information concerning notification of felony convictions has been reviewed by me and the following information is true to the best of my knowledge.

VENDOR’S NAME: AUTHORIZED COMPANY OFFICIAL’S NAME (PRINTED)

A. My firm is a publicly held corporation; therefore, this reporting requirement is not applicable. Signature of Company Official:

B. My firm is not owned nor operated by anyone who has been convicted of a felony. Signature of Company Official:

C. My firm is owned or operated by the following individual(s) who has/have been convicted of a felon.

Name of Felon(s): Details of Conviction(s): Signature of Company Official:

Revised 11/30/2015Form provided by Texas Ethics Commission www.ethics.state.tx.us

FORM CIQ

OFFICE USE ONLYThis questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session.

This questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a vendor whohas a business relationship as defined by Section 176.001(1-a) with a local governmental entity and thevendor meets requirements under Section 176.006(a).

By law this questionnaire must be filed with the records administrator of the local governmental entity not laterthan the 7th business day after the date the vendor becomes aware of facts that require the statement to befiled. See Section 176.006(a-1), Local Government Code.

A vendor commits an offense if the vendor knowingly violates Section 176.006, Local Government Code. Anoffense under this section is a misdemeanor.

CONFLICT OF INTEREST QUESTIONNAIREFor vendor doing business with local governmental entity

Date Received

A. Is the local government officer or a family member of the officer receiving or likely to receive taxable income,other than investment income, from the vendor?

Yes No

B. Is the vendor receiving or likely to receive taxable income, other than investment income, from or at the directionof the local government officer or a family member of the officer AND the taxable income is not received from thelocal governmental entity?

Yes No

7

Check this box if the vendor has given the local government officer or a family member of the officer one or more giftsas described in Section 176.003(a)(2)(B), excluding gifts described in Section 176.003(a-1).

Signature of vendor doing business with the governmental entity Date

Name of vendor who has a business relationship with local governmental entity.1

Check this box if you are filing an update to a previously filed questionnaire. (The law requires that you file an updated

completed questionnaire with the appropriate filing authority not later than the 7th business day after the date on which

you became aware that the originally filed questionnaire was incomplete or inaccurate.)

2

3 Name of local government officer about whom the information is being disclosed.

Name of Officer

Describe each employment or other business relationship with the local government officer, or a family member of theofficer, as described by Section 176.003(a)(2)(A). Also describe any family relationship with the local government officer.Complete subparts A and B for each employment or business relationship described. Attach additional pages to this FormCIQ as necessary.

4

6

5Describe each employment or business relationship that the vendor named in Section 1 maintains with a corporation orother business entity with respect to which the local government officer serves as an officer or director, or holds an

ownership interest of one percent or more.

Revised 11/30/2015Form provided by Texas Ethics Commission www.ethics.state.tx.us

CONFLICT OF INTEREST QUESTIONNAIRE

For vendor doing business with local governmental entity

A complete copy of Chapter 176 of the Local Government Code may be found at http://www.statutes.legis.state.tx.us/Docs/LG/htm/LG.176.htm. For easy reference, below are some of the sections cited on this form.

Local Government Code § 176.001(1-a): "Business relationship" means a connection between two or more partiesbased on commercial activity of one of the parties. The term does not include a connection based on:

(A) a transaction that is subject to rate or fee regulation by a federal, state, or local governmental entity or anagency of a federal, state, or local governmental entity;(B) a transaction conducted at a price and subject to terms available to the public; or(C) a purchase or lease of goods or services from a person that is chartered by a state or federal agency andthat is subject to regular examination by, and reporting to, that agency.

Local Government Code § 176.003(a)(2)(A) and (B):(a) A local government officer shall file a conflicts disclosure statement with respect to a vendor if:

***(2) the vendor:

(A) has an employment or other business relationship with the local government officer or afamily member of the officer that results in the officer or family member receiving taxableincome, other than investment income, that exceeds $2,500 during the 12-month periodpreceding the date that the officer becomes aware that

(i) a contract between the local governmental entity and vendor has been executed;or(ii) the local governmental entity is considering entering into a contract with thevendor;

(B) has given to the local government officer or a family member of the officer one or more giftsthat have an aggregate value of more than $100 in the 12-month period preceding the date theofficer becomes aware that:

(i) a contract between the local governmental entity and vendor has been executed; or (ii) the local governmental entity is considering entering into a contract with the vendor.

Local Government Code § 176.006(a) and (a-1)(a) A vendor shall file a completed conflict of interest questionnaire if the vendor has a business relationshipwith a local governmental entity and:

(1) has an employment or other business relationship with a local government officer of that localgovernmental entity, or a family member of the officer, described by Section 176.003(a)(2)(A);(2) has given a local government officer of that local governmental entity, or a family member of theofficer, one or more gifts with the aggregate value specified by Section 176.003(a)(2)(B), excluding anygift described by Section 176.003(a-1); or

(3) has a family relationship with a local government officer of that local governmental entity.(a-1) The completed conflict of interest questionnaire must be filed with the appropriate records administratornot later than the seventh business day after the later of: (1) the date that the vendor:

(A) begins discussions or negotiations to enter into a contract with the local governmentalentity; or(B) submits to the local governmental entity an application, response to a request for proposalsor bids, correspondence, or another writing related to a potential contract with the localgovernmental entity; or

(2) the date the vendor becomes aware:(A) of an employment or other business relationship with a local government officer, or afamily member of the officer, described by Subsection (a);(B) that the vendor has given one or more gifts described by Subsection (a); or(C) of a family relationship with a local government officer.

DPS Computerized Criminal History (CCH) Verification

(AGENCY COPY)

I, , acknowledge that a Computerized Criminal APPLICANT or EMPLOYEE NAME (Please print)

History (CCH) check will be performed by accessing the Texas Department of Public Safety Secure

Website and will be based on name and DOB identifiers I supply. (This is not a consent form.) Authority

for this agency to access an individual’s criminal history data may be found in Texas Government Code

411; Subchapter F.

Name-based information is not an exact search and only fingerprint record searches represent

true identification to criminal history, therefore the organization conducting the criminal history check is

not allowed to discuss with me any criminal history record information obtained using this method. The

agency may request that I have a fingerprint search performed to clear any misidentification based on

the result of the name and DOB search. Once this process is completed the information on my

fingerprint criminal history record may be discussed with me.

In order to complete the process I must make an appointment with the Fingerprint Applicant

Services of Texas (FAST) as instructed online at www.txdps.state.tx.us /Crime Records/Review of

Personal Criminal History or by calling the DPS Program Vendor at 1-888-467-2080, submit a full and

complete set of fingerprints, request a copy be sent to the agency listed below, and pay a fee of $24.95 to

the fingerprinting services company.

(This copy must remain on file by your agency. Required for future DPS Audits)

___________________________________ Signature of Applicant or Employee

Date

Agency Name (Please print)

Agency Representative Name (Please print)

___________________________________ Signature of Agency Representative

Date

Rev. 09/2013

Please: Check and Initial each Applicable Space

CCH Report Printed: YES NO initial Purpose of CCH: Empl Vol/Contractor initial Date Printed:

/

initial Destroyed Date: initial

Retain in your files



PROPOSAL SPECIFICATIONS REQUIREMENTS TO BE FILLED IN BY OFFEROR AND SUBMITTED WITH PROPOSAL

Is this proposal in conformance with the enclosed specifications? Yes ___ No ___ If the answer is no, offeror must identify and explain each exception taken, with reference to each page and paragraph to which the exception will apply. It should be understood that if no exception is taken the vendor shall supply all items as specified at the time of sale. Failure to indicate any difference in products offered proposed in this proposal may be deemed sufficient grounds for rejection of a vendor’s proposal. Comments:

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________ __________________ ________________ __________________________ RFP Number Date Company Name



LIST FOUR SCHOOL DISTRICTS WHICH YOUR COMPANY HAS DONE BUSINESS WITH WITHIN THE LAST TWO (2) YEARS. FAILURE TO DO SO MAY RESULT IN THE REJECTION OF YOUR PROPOSAL.

REFERENCE SHEET

Company Name: ___________________________________________________ Contact Name: ___________________________________________________ Address: ___________________________________________________ City: ____________________ State: ______ Zip Code: __________ Phone Number: _____________________ Fax Number: __________________

Company Name: ___________________________________________________ Contact Name: ___________________________________________________ Address: ___________________________________________________ City: ____________________ State: ______ Zip Code: ___________ Phone Number: _____________________ Fax Number: ___________________ Company Name: ___________________________________________________ Contact Name: ___________________________________________________ Address: ___________________________________________________ City: ____________________ State: ______ Zip Code: ___________ Phone Number: _____________________ Fax Number: ___________________ Company Name: ___________________________________________________ Contact Name: ___________________________________________________ Address: ___________________________________________________ City: ____________________ State: ______ Zip Code: ___________ Phone Number: _____________________ Fax Number: ___________________



NON-COLLUSION STATEMENT & SIGNATURE SHEET The undersigned affirms that he/she is duly authorized to execute this contract, that this company, corporation, firm partnership or individual has not prepared this proposal in collusion with any other bidder and that the contents of this proposal as to prices, terms or conditions of said proposal have not been communicated by the undersigned nor by any employee or agent to any other person engaged in this type of business, or to any person affiliated with Raymondville I.S.D., prior to the official opening of this proposal.

I, ___________________________________, have read the standard terms and conditions. (Print/Type Name of Company Officer)

I fully understand them and will fully execute them if I am awarded this proposal.

I have represented the truth concerning the felony conviction notification.

I fully understand the proposal specifications.

Company Name: ______________________________________________

Address: ____________________________________________________

City, State: ______________________________Zip Code: ____________

Phone Number: _________________ Fax Number: _________________

Authorized Signature: __________________________________________

Bidder (Print Name): ___________________________________________

Official Position with Company: _________________________________

Form W-9(Rev. October 2018)Department of the Treasury Internal Revenue Service

Request for Taxpayer Identification Number and Certification

▶ Go to www.irs.gov/FormW9 for instructions and the latest information.

Give Form to the requester. Do not send to the IRS.

Pri

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pec

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Inst

ruct

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pag

e 3.

1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.

2 Business name/disregarded entity name, if different from above

3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the following seven boxes.

Individual/sole proprietor or single-member LLC

C Corporation S Corporation Partnership Trust/estate

Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) ▶

Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that is disregarded from the owner should check the appropriate box for the tax classification of its owner.

Other (see instructions) ▶

4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):

Exempt payee code (if any)

Exemption from FATCA reporting

code (if any)

(Applies to accounts maintained outside the U.S.)

5 Address (number, street, and apt. or suite no.) See instructions.

6 City, state, and ZIP code

Requester’s name and address (optional)

7 List account number(s) here (optional)

Part I Taxpayer Identification Number (TIN)Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later.

Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter.

Social security number

– –

orEmployer identification number

–

Part II CertificationUnder penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue

Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and

3. I am a U.S. citizen or other U.S. person (defined below); and

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.

Sign Here

Signature of U.S. person ▶ Date ▶

General InstructionsSection references are to the Internal Revenue Code unless otherwise noted.

Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/FormW9.

Purpose of FormAn individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following.

• Form 1099-INT (interest earned or paid)

• Form 1099-DIV (dividends, including those from stocks or mutual funds)

• Form 1099-MISC (various types of income, prizes, awards, or gross proceeds)

• Form 1099-B (stock or mutual fund sales and certain other transactions by brokers)

• Form 1099-S (proceeds from real estate transactions)

• Form 1099-K (merchant card and third party network transactions)

• Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition)

• Form 1099-C (canceled debt)

• Form 1099-A (acquisition or abandonment of secured property)

Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN.

If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later.

Cat. No. 10231X Form W-9 (Rev. 10-2018)

Item MFR MOD# QTY DESCRIPTION Price1 CANON M40K701C-R 1 DEMO RadPRO Mobile 40kW DR Mobile X-Ray with Enhanced Workflow ready for and with $

DEMO Canon CXDI-70C Wireless DR Detector

Includes:

� Battery Assisted 40kW High Frequency generator

� Microprocessor Controlled

� Auto diagnostic System for easy maintenance.

� Tube overload protection continuously Monitoring of the remaining X-Ray Tube Heat Units

� Anatomical Programmer APR with more than 500 program capability.

� Automatic selection of the radiographic parameters programmed (kVp., mA, time or

mAs and focal spot, according with patient size and anatomical area selected).

� KVp Range from 40 KVp to 150 KVp in 1 KVp Steps.

� mA range from 10 to 500 mA in Renard scale: 10, 12.5, 16, 20, 25, 32, 40, 50, 63, 80,

100, 125, 160, 200, 250, 320, 400, 500 mA

� mAs Range 0.1 to 500 mAs.

� Time range from 1 ms. to 8 sec. 40 Time stations. Renard Scale

� User Friendly Touch Control Panel with Digital Displays for KVp, mAs, mA and time.

� Two and three points console.

� Two point console KVp and mAs selection only.

� Three point console KVp, mA and time selection.

� Two step Hand switch for preparation and exposure.

� Audible and light indication for x-ray exposure.

� Line requirement: 110/230 VAC single phase ±10%

� 15aH Batteries for PC/Exposure, 9aH Batteries for Drive System

� LED Collimator with User-Controlled On/Off

� Green/Yellow/Red Battery Monitor System

� 17" Touch-Screen Console

� On/Off Switch Modification Kit for RadPro Digital Mobiles

� Parallel Charging allows for RadPRO Mobile to remain on while charging

� Expose while plugged in (technologist must be logged in) for redundancy & disaster recovery

� 300KHU 0.7 - 1.3 Focal Spot X-Ray Tube

Enhanced Workflow:

� Capable of concurrently running any third party application such as Cerner or client PACS

� Switch to toggle between Canon NE application and third party applications

� Integrated Touch Pad to add mouse functionality for third party applications

Tube Stand Column Mobile Unit:

� Motorized Unit. 4 km/h Speed. Pressure Sensitive Moving System (Patent).

� Two Independent Motors one for each wheel. Forward and Backward movement.

� Excellent mobility with large rear wheels for easy transportation even over small obstacles.

� Independent Battery Charge Indicators for Driving and Generator Batteries.

� "Precise-Positioning Buttons" allows base to be driven forward, backward &rotate from tube-head.

� Anti Collision System. Frontal and Lateral.

� Easy access to any elevator, hall-way, doors and patient bed side.

� Quick and sturdy breaking system control when operator releases the handle.

� Manual rotary collimator with x-ray covers area light indication.

� Possibility of Lighting the Collimator from booth Collimator and Front Panel.

� Ergonomic touch control panel with sensitive push button.

� Emergency Stop push button, clearly accessible.

� Tube stand column rotation +/- 315º

� Tube rotation "X" axis +/- 155º

� Tube rotation "Z" axis 90º

� Vertical tube travel 57" (145 cm)

� Horizontal tube travel 23.6" (60 cm)

� Counterbalanced tube arm.

� Electromagnetic breaks with release from the Collimator and Front Handle

� Maximum Focal Distance 74.4" (1890mm) to the floor

� Minimum Focal Distance 21.6" (550mm) to the floor

Computer: High performance control unit with wireless data communications

PC Specifications:� Intel i7 Quad Core Processor� 8 GB High-Speed RAM

1


http://www.raymondvilleisd.orgPhone: (956) 689-8175

Fax: (956) 689-8180

Or Equal Or Equal

Portable X-Ray Machine

Item MFR MOD# QTY DESCRIPTION Price� 250 GB SSD (Solid State Drive) Hard Drive� Microsoft Windows 7 64-Bit Operating System� Custom designed advanced WiFi system - 802.11a/b/g/n Dual band (2.4-5.0 GHz)� Wireless transmission of images from PC to network storage (PACS) or print location� Ruggedize Chassis designed to withstand severe shock and continual vibration, making themideal for use in a portable environment.� Fully integrated retractable ethernet will connect you to your PACS network to transfer yourDICOM images.� Stylus

Wireless Access Point

� Transmits image from CXDI-70C Wireless to on-board Control PC� Non-broadcasting, one-to-one paired with Canon CXDI-70C Wireless detectors only� WPA/PSK2 data encryption� Dual-Band 802.11n transmission

Infrared Check-In Unit

� Allows CXDI-70C Wireless to be 'checked-in' to Control PC� Up to 10 detectors can be associated with one Control PC

Gigabit Ethernet Switch

Canon X-Ray Interface Unit

Canon Battery Charging Unit

� Charges two batteries at once (New Batteries)� Quick charging, full recharge in <3 Hours from zero� Indicator lights for when battery is charging and fully charged

Control Software NE Features:

System Startup & Quality Assurance� Standard Mode: No log-in required� Secure Mode: Operator log-in/password required (user authentication); auto time-out with log-in to last screen viewed� Warm-up time: None� Battery/Wi-Fi Monitor: Software to allow wi-fi strength monitor & battery monitor forCXDI-70C Wireless configuration� Calibration Routine: Included; required once/year; configurable on-screen reminder message� Display QA: SMPTE pattern included

Image Acquisition

� Programming: Unlimited anatomically programmed acquisition settings; user customizable to include annotation, orientation, patient demographics display location, and pre-selected basic and enhancement processing� Reject/Retake: Reject, Retake, Un-Reject; Reject reason labeling with free or pre-set annotation; Reject log (.csv monthly file accessible to system administrator for rolling 12mos)� Grid Suppression: Software-based grid suppression� Protocol Pre-Pack: Allows for multiple APR views to be associated into one APR for easy grouping of views within a study.� Auto-Stitch (v1.2): Multiple images can be stitched together within the software.

Image Processing

� Basic Processing: Histogram analysis by automatic fixed region ROI or user adjustable ROI; grayscale conversion; adjustable brightness &contrast; 6 pre-set contrast enhancement curves; collimation edge detection & (black) masking w/ adjustable standoff; trim positioning & adjustment� MTF Improvement: Preset & user-selectable/adjustable anatomical region-based filters, intensity levels� Standard Processing: Preset & user- selectable/adjustable DEP (dynamic range adjustment), edge enhancement, noise reduction� Preset and adjustable multi-frequency dynamic range adjustment; global edge enhancement� Preset & user-select/adjustable dynamic range adjustment; noise reduction, local edge enhancement� Security advancements allow for only select users to access full image processing protocols.

Data Output and Network Connection

� DICOM Print Format: Multi-format, user selectable pre-exposure & post-exposure formatting; selectable printing method (fixed ratio, life size, reduction, fit to film); queue viewable with priority & cancel capab.up to 2 DICOM printers may be specified at any one time, up to 4 DICOM printers may be configured.;� Study transmission: Selectable modes - after each image, after study end, post-study retrieval with resend individual or all image capabilities; queue viewable with priority and cancel capabilities; up to 2 storage devices may be specified at any one time, up to 4 storage devices may be configured� CD Archive: Available as network selectable storage device with DICOMDIR (hardware not included)� Network: Ethernet 10/100/1000 Base T, RJ45 standard� Data Output: DX; DICOM 3.0 compliant, Print Mngmentt Service Class, Storage Service Class & others� IHE Profiles: Basic Security Profile option - User Authentication, Audit Log, Time Synchronization, Node Authentication

DICOM Modality Worklist for Canon CXDI Digital Radiography systems is a communications module for

acquiring patient information and exam requirements from the HIS / RIS. The following features are available in this module:

Study Information Acquisition

� Study is configurable to include a wide variety of patient information such as name, sex, birth date, age, patient ID, accession number(s), referring physician, etc.� Find Mode is available and conforms to Modality Worklist SOP Class (MWL).� Patient information can be entered manually if the patient does not appear on the worklist.� When used with a portable imaging unit, the worklist can be downloaded and stored in the control

2

Item MFR MOD# QTY DESCRIPTION Pricecomputer eliminating the need for network access at the patient's bedside. A barcode reader (not included) can be used to find and select the patient from the worklist.

Study Status Notification

� Supports Modality Performed Procedure Step SOP Class (PPS) with in progress, completed, ordiscontinued messages.� PPS is available for both suite and portable imaging� Multi-accession imaging

Imaging Modes

� Manual imaging mode allows the user to individually select each view to be acquired� Program imaging mode uses the study information sent by the HIS / RIS to pre-configure the exam(s)to be performed� Images can be acquired in any order� Additional views can added at any point in the exam� The study can be ended without completing all views� 100 views can be acquired for a single patient� Exams and views can be customized to meet the needs of the facility� Requires Program Imaging Mode Set Up and Implementation Fee Any license fee for third party software applications will be the responsibility of the customer

Optional DICOM tags can be defined, displayed, printed, and transmitted to PACS.

Pregnancy Status can be received from HIS / RIS and an alert displayed to inform the user of the status.

Storage Commit function is available.

Keypad

1 DEMO 701C Wireless Cassette Sized Cesium DR Panel

Specifications

Detector

� Method: Cassette Size Detector, Scintillator & Amorphous Silicon (a-Si)� Scintillator: Csl (Csl: TI)� Sensor: LANMIT (Large Area New-MIS sensor and TFT)� Pixel Pitch: 125 Microns� Pixels: 2,800 x 3,408 Pixels (9.5 Megapixels)� Imaging Area: 14 x 17 in (35 x 43 cm)� Standard Configuration: Sensor Unit, X-Ray Interface Box, Battery Charger, DetectorCheck-In Unit, Wireless Access Point (Including A/C Power)

Battery

� Life; Up to 6.5 Hours or 140 images� Recharge Time: Less Than 3 Hours� Performance: Approximately 140 Images

Image Acquisition and Processing

� Image Processing: Standard Advanced Multi-Frequency Processing� A/D: 16-bit� Grayscale Output: 12 bit or 16 bit selectable� Preview Image: Approximately 1-2 Seconds After X-ray Exposure� Cycle Time: Approximately 5-6 Seconds After X-ray Exposure

Data Output and Network Connection

� Wireless Standard: IEEE 802.11n (5 & 2.4 GHz)� DICOM 3.0 Compatible, Print Management (SCU), Storage (SCU), MWL (SCU), MPPS (SCU)

Electrical and Environmental

� Operating Environment Sensor: 41-95°F (5-35°C), Humidity 30-80% RH (non-condensing)

Physical Characteristics

� Dimensions (W x L x H): 15.1 x 18.1 x 0.6 in (384 x 460 x 15 mm)(Detector unit only)� Weight: 7.3 lbs (3.3 kg) (with battery)

2 REINA C701CW 1 70/701C Wireless Snap-on 14 x 17, 8:1, 132lpi, 40-72 Lightweight Protect-A-Grid with Handle $

Services & Warranty:

One Day Applications Training

Onsite/Remote assistance with PACS connectivity

1 Year Parts and Labor Warranty, followed by 6 Months Factory Parts Warranty

1 Year Technical Support

State & Federal Registration

Site Planning & Consulting

3

Or Equal Or Equal

Item MOD# QTY DESCRIPTION Price

SUB TOTAL: $ SALES TXFREIGHT $ TOTAL $

Customer Name and Signature Date

4

$

Item MFR MOD# QTY DESCRIPTION Price1 AMERICOMP SPEC30HF-S 1 $

1

SPECTRA 30HF SIMULATOR CONSOLE W/4-WAY FLOAT TOP TABLE, TUBESTAND,

NON-ENERGIZED X-RAY TUBE, LIVE COLLIMATOR AND WALLSTAND

Include:

Simulator Console Spectra 30HF AP

� Technique selections: kVp/ mAs and Anatomical programming

� Allows prep and exposure simulation with audible and visual exposure indicator

� Operates on 120 VAC electrical service

1 Float Top Table

� Four-way float top table with foot treadle control

� 84” x 30” table top, table height 31.5”

� Grid cabinet with electric lock, 22” travel

� Heavy-duty cassette tray

� 400 lb. rated patient load

1 Transverse Rotational Tubestand

� Floor-to-wall or floor-to-ceiling mount with 8 ft. rails

� Rotational base, +/- 180 degrees with 90 degree detents

� Transverse tubearm +/- 5”, port-style tube mount

� Angulation dial, operator handgrips, and electric locks

� Operates on 24 VDC

1 Wallstand Package

� Floor-to-wall mount column

� Grid cabinet, 17” x 17”

� Heavy-duty cassette tray

� Electric lock

� External 24 VDC power supply

1 X-Ray Tube – Non operational

� Rotor does not spin, no x-ray

1 Collimator

� Certified manual collimator with light field and swivel mount

� Power supply for Collimator

Services & Warranty:

* 1 Year Parts & Labor Warranty, followed by 4 Years Factory Parts Warranty

* 1 Year Technical Support

* Installation and Training

SUB TOTAL: $

SALES TX

FREIGHT $

Customer Name and Signature Date TOTAL $

1


http://www.raymondvilleisd.orgPhone: (956) 689-8175

Fax: (956) 689-8180

or Equal or Equal

X-Ray Simulator

Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 12/22/2017

FORM 1295CERTIFICATE OF INTERESTED PARTIES

OFFICE USE ONLOFFICE USE ONLOFFICE USE ONLOFFICE USE ONLOFFICE USE ONLYYYYY

6 UNSWORN DECLARATION

My name is _______________________________________________________, and my date of birth is _______________________________.

My address is ________________________________________________, ___________________, _______, __________, ______________.

(street) (city) (state) (zip code) (country)

I declare under penalty of perjury that the foregoing is true and correct.

Executed in ___________________ County, State of ______________ , on the _______ day of _______________, 20______.

(month) (year)

Signature of authorized agent of contracting business entity(Declarant)

ADD ADDITIONAL PAGES AS NECESSARY

Name of Interested PartyNature of Interest (check applicable)City, State, Country

(place of business)Controlling Intermediary

4

Name of governmental entity or state agency that is a party to the contract forwhich the form is being filed.

2

3 Provide the identification number used by the governmental entity or state agency to track or identify the contract,and provide a description of the services, goods, or other property to be provided under the contract.

Complete Nos. 1 - 4 and 6 if there are interested parties.Complete Nos. 1, 2, 3, 5, and 6 if there are no interested parties.

1 Name of business entity filing form, and the city, state and country of the businessentity's place of business.

5Check only if there is NO Interested Party.

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RAYMONDVILLE INDEPENDENT SCHOOL DISTRICT CERTIFICATE OF INTERESTED PARTIES – FORM 1295

Definitions and Instructions for Completing Form 1295

Raymondville Independent School District is required to comply with House Bill 1295, which amended the Texas Government Code by adding Section 2252.908, Disclosure of Interested Parties. Section 2252.908 prohibits RISD, or its cooperative members, from entering into a contract resulting from this RFP with a business entity unless the business entity submits a Disclosure of Interested Parties – Form 1295 to RISD at the time the business entity submits the signed contract. The Texas Ethics Commission has adopted rules requiring the business entity to file Form 1295 electronically with the Texas Ethics Commission.

As a “business entity,” all vendors must electronically complete, print, sign, notarize and submit Form 1295 with their proposals or contracts even if no interested parties exist.

Proposers must file Certificate of Interested Parties – Form 1295 with the Texas Ethics Commission using the following online application: https://www.ethics.state.tx.us/whatsnew/elf_info_form1295.htm

Proposers must use the filing application on the Texas Ethics Commission’s website (see link above) to enter the requiredinformation on Form 1295.

Proposers must print a copy of the completed form, which will include a certification of filing containing a uniquecertification number.

The Form 1295 must be printed and then signed by an authorized agent of the business entity, and the form must benotarized.

The completed Form 1295 with the certification of filing must be filed with Raymondville Independent School District byincluding a copy of the completed/notarized form with the proposal response.

RISD must acknowledge the receipt of the filed Form 1295 by notifying the Texas Ethics Commission of the receipt of thefiled Form 1295 no later than the 30

th day after the date the contract binds all parties to the contract.

After RISD acknowledges the Form 1295, the Texas Ethics Commission will post the completed Form 1295 to its websitewithin seven (7) business days after receiving notice from RISD.

Instructions to Vendors: 1. Read these instructions,2. Go to the Ethics Commission Website

https://www.ethics.state.tx.us/whatsnew/elf_info_form1295.htm,3. Register and complete Form 1295 online - include the proposal number and the contract/RFP name,4. Print a copy of the submitted Form 1295 and have it notarized - it will have a certification # in the top

right corner,5. Include a copy of the completed, signed and notarized Form 1295 with the proposal response.

Definitions:

Interested Party: a person who:1) has controlling interest in a business entity with whom RISD and/or its cooperative members

contracts; or2) actively participates in facilitating the contract or negotiating the terms of the contract, including a

broker, intermediary, adviser, or attorney for the business entity.

Controlling Interest means:

1) an ownership interest or participating interest in a business entity by virtue of units, percentage,shares, stock, or otherwise that exceeds 10 percent;

2) membership on the board of directors or other governing body of a business entity of which the boardor other governing body is composed of not more than 10 members; or

3) service as an officer of a business entity that has four or fewer officers, or service as one of the fourofficers most highly compensated by a business entity that has more than four officers.

Intermediary: a person who actively participates in the facilitation of the contract or negotiation the contract, including abroker, advisor, attorney, or representative of or agent for the business entity who:

a) receives compensation from the business entity for the person’s participation;b) communicates directly with the governmental entity or state agency on behalf of the business entity

regarding the contract; andc) is not an employee of the business entity.

Business Entity: includes an entity through which business is conducted with a governmental entity or state agency,regardless of whether the entity is a for-profit or nonprofit entity.

Resources: Form 1295 Frequently Asked Questions:

https://www.ethics.state.tx.us/whatsnew/FAQ_Form1295.htmlInstructional Video – First Time Business User:

https://www.ethics.state.tx.us/filinginfo/videos/Form1295/FirstLogin-Business/Form1295Login-Business.htmlInstructional Video – How to Create a Certificate:

https://www.ethics.state.tx.us/filinginfo/videos/Form1295/CreateCertificate/CreateCertificate.html

https://www.ethics.state.tx.us/whatsnew/elf_info_form1295.htm

https://www.ethics.state.tx.us/whatsnew/elf_info_form1295.htm

https://www.ethics.state.tx.us/whatsnew/FAQ_Form1295.html

https://www.ethics.state.tx.us/filinginfo/videos/Form1295/FirstLogin-Business/Form1295Login-Business.html

https://www.ethics.state.tx.us/filinginfo/videos/Form1295/CreateCertificate/CreateCertificate.html


House Bill 89 Verification

I, ______________________________ (Person name), the undersigned representative

of ___________________________ / _______________________________________ (Company or Business name) (Company or Business address)

(hereafter referred to as company) being an adult over the age of eighteen (18) years of age, after being duly sworn by the undersigned notary, do hereby depose and verify under oath that the company named above, under the provisions of Subtitle F, Title 10, Government Code Chapter 2270:

1. Does not boycott Israel currently; and2. Will not boycott Israel during the term of the contract.

Pursuant to Section 2270.001, Texas Government Code:

1. "Boycott Israel" means refusing to deal with, terminating business activities with, orotherwise taking any action that is intended to penalize, inflict economic harm on, orlimit commercial relations specifically with Israel, or with a person or entity doingbusiness in Israel or in an Israeli-controlled territory, but does not include an actionmade for ordinary business purposes; and

2. "Company" means a for-profit sole proprietorship, organization, association,corporation, partnership, joint venture, limited partnership, limited liabilitypartnership, or any limited liability company, including o wholly owned subsidiary,majority-owned subsidiary, parent company or affiliate of those entities or businessassociations that exist to make a profit.

_____________________ ________________________________________ DATE SIGNATURE OF COMPANY REPRESENTATIVE

On this the _____ day of _______________________, 20 ____, personally appeared

_________________________________ the above-named person, who after by me being duly sworn, did swear and confirm that the above is true and correct.

NOTARY SEAL _____________________________ NOTARY SIGNATURE

_____________________________

Date

RAYMONDVILLE INDEPENDENT SCHOOL DISTRICT PURCHASING DEPARTMENT

SENATE BILL 252 CERTIFICATION

I, _________________________________ the Undersigned, representative of

____________________________________________________________ (company or business name)

located in_______________________________, ____________________ (city) (state)

being an adult over the age of eighteen (18) years of age, pursuant to Texas Government Code, Chapter 2252, Section 2252.152 and Section 2252.153, certify that the company named above is not listed on the website of the Comptroller of the State of Texas concerning the listing of companies that are identified under Section 806.051, Section807.051 or Section 2253.153.

I further certify that should the above-named company enter into a contract that is on said listing of companies on the website of the Comptroller of the State of Texas which do business with Iran, Sudan or any Foreign Terrorist Organization, I will immediately notify the Raymondville Independent School District Purchasing Department.

__________________________________________ Name of Company Representative (Print)

__________________________________________ Title of Company Representative (Print)

__________________________________________ Signature of Company Representative

__________________________________________ Date

On this the _______ day of ___________________________, 20 ____, personally appeared

_______________________________ the above-named person, who after by me being duly sworn, did swear and confirm that the above is true and correct.

NOTARY SEAL _____________________________ NOTARY SIGNATURE

_____________________________

Date



DELIVERY INSTRUCTIONS:

1. No deliveries accepted after 4:00 p.m., Monday-Friday. Shipping & Receiving Department is closedbetween 12:00 noon and 1:00 p.m. Monday-Friday.

2. Furniture or Heavy Merchandise deliveries, please give twenty-four (24) hour notifications.

3. Each and every carton must be marked as indicated on purchase order.

4. Can you meet the delivery guidelines request above? Yes ______ No ______

COMMENTS:

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Contact Person if further delivery information is needed:

Andres Villalpando, Coordinator for Purchasing

(956) 689-8175 ext. 4129

BILLING AND PAYMENT INSTRUCTIONS:

1. Invoice must include:

Purchase Order Number

Invoice shall be sent to the Raymondville Independent School District Business Office,Attn: Accounts Payable, 419 FM 3168, RAYMONDVILLE, TX 78580 for payment

2. The District makes payment within thirty (30) days of a properly executed invoice and verifications ofdelivery from consignee.

3. Should there be damaged merchandise; District will not make invoice payment until matter is resolved.(i.e. returned or replaced)

Contact person for billing and payment questions:

AnnaBelle White, Accounts Payable

(956) 689-8175 ext. 4105

Email: [email protected]

sharyland independent school district · san juanita (janie) cruz - member ben clinton “it all...

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