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Shelby County MARK H. LUTTRELL, JR, MAYOR Tennessee

REQUEST FOR QUOTATION

BID DESCRIPTION: 2018 Single Axle Dump Trucks w/ a Central Hydraulic System

COMMODITY: 070-51 Dump Trucks

(Code No. and Description)

BID NUMBER: SEALED BID I000502 (MC 568)

(Sealed Bid or Regular Bid)

DUE DATE: NO LATER THAN 2:00 pm (CST) Monday April 9, 2018 (TIME) (DAY) (DATE)

ORIGINAL SPECIFICATIONS (REVISED) SPECIFICATIONS

160 NORTH MAIN STREET, MEMPHIS, TENNESSEE 38103

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Section III Detailed Requirements / Scope of Work / Specifications

1. REQUIREMENTS TO BE “RESPONSIVE”

2. BONDS / LICENSES / INSURANCES

3. WARRANTIES

4. LITERATURE / MANUALS / PUBLICATIONS

5. STANDARDS

6. SPECIFICATIONS / SCOPE

7. DEMONSTRATION OF GOODS/SERVICES

8. EQUAL / EQUIVALENT PRODUCTS

9. DEVIATIONS TO SPECIFICATIONS

10. SPECIAL PACKAGING

11. DELIVERIES / F.O.B. POINT

12. LOCATIONS

13. RIGHTS OF INSPECTION AND/OR SAMPLING

14. FIRM PRICES / DISCOUNTS / QUANTITIES / RENEWALS

15. PAYMENT SCHEDULE

16. AWARDS

17. CONTRACT / AWARD LETTER / CANCELLATION

18. ORDERS

19. ADDITIONAL INFORMATION FROM THE BIDDER

20. LOSB and M/WBE

21. QUESTIONS / INQUIRIES

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IMPORTANT NOTES: MANDATORY INFORMATION and FORMS – To properly respond and prepare

your proposal response, please make sure you pay close attention to all mandatory

information/forms requested, including sign and attach all forms listed in Section III.1.

This bid clearly documents and outlines the format and what information is required at

the time of proposal submission (vs later, only for the successful vendor(s)).

Sincerely,

Signed Original on File

Sonja Worthy, Buyer Shelby County Government

Purchasing Department

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1. REQUIREMENTS TO BE “RESPONSIVE”

Shelby County Government, (the “County”), is soliciting proposals from interested and qualified Vendors to provide two (2) new & unused single axle dump trucks with

central hydraulic system (the “Goods and/or Services”). This Sealed Bid is being released to invite interested and qualified Vendors to prepare and submit proposals in accordance with instructions provided where the successful proposer(s) will be selected and invited to enter into a contractual relationship with Shelby County for the Goods and/or Services outlined in this sealed bid, and per proposal(s) received. In this Sealed Bid, the terms Proposer, Vendor, Bidder, Consultant, Contractor, Professional are used interchangeably unless the context indicates otherwise. All specifications are part of this bid and general terms and conditions (as outlined in the Terms of this bid). They shall become a part of and be included in any contract/purchase order/systems contract resulting from any award. These specifications are not intentionally written to favor any one manufacturer or service provider, and are only for the purpose of indicating generally the type of work required of said bid. Any responsible Bidder who considers these specifications to be of a non-competitive nature should immediately contact the Administrator of Purchasing.

In order to be considered as “responsive”, all Proposers must answer and provide

justifications for ALL below minimal requirements (unless specifically marked for

“LATER”):

1. All appropriate Licenses and Certifications required in the State of Tennessee to provide the goods and/or perform the Services required, procure all permits, pay all charges, taxes and fees – please list each of them, as well as their respective numbers and expiration dates.

2. Active Equal Opportunity Compliance (EOC) number(s); or your application is “in” the EOC system for processing (refer to details outlined below) – please list all your Shelby County EOC active numbers.

3. FORM - Drug Free Workplace Affidavit must be completed, signed and submitted with your bid/proposal – even if less than 5 employees.

4. LATER, only for the successful vendor(s) during contract negotiations – Active Vendor

number.

5. LATER, only for the successful vendor(s) during contract negotiations – FORM -

Gratuity Disclosure Form must be completed, signed and submitted.

WITHIN A REASONABLE PERIOD FROM THE TIME OF RECEIVING THE AWARD LETTER(s), THE SUCCESSFUL VENDOR(s) MUST PRODUCE ALL ABOVE MINIMAL REQUIREMENTS LABELED AS “LATER” TO THE SHELBY COUNTY ROADS, BRIDGES & ENGINEERING DEPARTMENT. FAILURE TO DO SO SHALL RESULT IN THE AWARD BEING RESCINDED.

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Shelby County EOC and Vendor numbers:

As a part of doing business with Shelby County, each individual, company or organization is required to have active EOC and Vendor numbers before starting providing goods/services to SCG:

1. obtain a SCG “Equal Opportunity Compliance” certification number (acquired through the EOC Department, partially online then bring/mail/fax),

AND 2. obtain a SCG Vendor number (acquired through the Purchasing Department,

online only), as explained below:

1. To obtain an EOC number (as well as LOSB/MWBE numbers, if applicable): Link: http://www.shelbycountytn.gov/509/Contract-Compliance-Program Please print the packet and bring/mail/fax the completed packet to the EOC office. Should any further assistance be needed, contact the EOC office directly (not Purchasing). EOC office hours are from 8:00 a.m. to 4:30 p.m. Monday through Friday and we welcome your visits.

Shelby County Government 160 N. Main

2nd Floor – Equal Opportunity Compliance (EOC)

Memphis, TN 38103 Reception: 901-222-1100

Fax: 901-222-1101 If your company (or your sub(s)) does NOT have an ACTIVE EOC number at the time of the bid, please ensure EOC has your (or their(s)) application or renewal “in” their system at the time of the bid, for their processing (assuming successful). Because of the length of time required to receive an EOC number, proposals from vendors who submit an application prior to the bid due date will be accepted, pending EOC approval of their application.

2. To obtain a Vendor number: Link: https://forms.shelbycountytn.gov/lfserver/vendorapplication Complete the application and submit online only. You will then be emailed a W-9 form in which you are to print, sign and date. The original signed and dated copy is needed on file in our office. You have the option to mail the W-9 or walk it in. A faxed or scanned copy cannot be accepted. The copy of the application that you receive via email is yours to keep on file. NOTE: upon receiving the EOC number, Purchasing will create your Vendor number

and you will receive it via email.

Should any further assistance be needed, contact the Purchasing office directly (not EOC).

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A vendor kiosk is available for public use. Purchasing office hours are from 8:00 a.m. to 4:30 p.m. Monday through Friday and we welcome your visits.

Shelby County Government 160 N. Main

9th Floor – Purchasing Department

Memphis, TN 38103 901-222-2250

Because an EOC number is required to receive a Vendor number, the successful Vendor(s) will have to get an active Vendor number before contract signature and start providing the goods/services to SCG, i.e not required at the time of proposal submission.

2. BONDS / LICENSES / INSURANCES

Bid Bond(s):

N/A

License(s), Classification(s) and Certification(s):

Have all appropriate Licenses and Certifications required in the State of Tennessee to perform the Goods/Services required and procure all permits, pay all charges, taxes and fees – please identify clearly on your envelope.

Insurance(s): N/A

3. WARRANTIES

Vendor shall state warranty for each equipment bid; submit as an attachment to the response. Vendor shall furnish standard warranty information from the vehicle/equipment manufacturer.

4. LITERATURE / MANUALS / PUBLICATIONS

We request all pertinent information setting out and describing vehicle/equipment being offered; submit as an attachment to the response. Successful Vendor must supply a Parts and Operations manual for each vehicle/equipment item awarded. Successful vendor must supply the following to the department that is receiving the vehicle/equipment.

a. Operator/service manuals for vehicle/equipment

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b. Current bulletin(s) to Motor Vehicle Management, or all problem areas noted by the manufacturer for the specific vehicle; and

c. One complete parts and operation manual to be furnished by successful Vendor. Any specifics OUTSIDE of the specifications shall be stated ONLY in the bid response notes.

Shelby County Government will not accept alternate bids (except if Construction) and/or

which are not equal in specifications.

5. STANDARDS

The Specifications contained in this bid are considered the standard base vehicle/equipment for this bid. The standard base vehicle/equipment may include items that are not included as standard by the manufacturer. When these items are included in the Specifications, the bidder must include the cost of these items in the bid.

6. SPECIFICATIONS / SCOPE

Shelby County wishes to engage the Vendor(s) selected through a competitive process that will work well with the County’s personnel in the performance of the Goods/Services, in a cost-effective manner. The intent of this request is for Shelby County Government to obtain two (2) new & unused single axle dump trucks with central hydraulic system to operate a hoist and a material spreader/spinner that would be attached in the bed. The units, including all necessary equipment shall be furnished complete and ready for use. All parts not specifically mentioned, but which are required for a complete unit shall be furnished according to the current standard design of the manufacturer. Bidder must be an authorized sales, parts, and service facility for the make that it represents. Bidders must be capable of performing warranty work on all truck components. Bidder must carry an adequate inventory of parts necessary for making repairs. Bidder shall certify that the equipment proposed is in complete compliance with all OSHA requirements when manufactured.

Detailed Specifications

SINGLE AXLE DUMP TRUCK DESCRIPTION:

2018 Single axle construction dump GVW Rating 35,000 lbs. minimum

Cab to Axle- 84 inches Wheel Base - 152 inches approximately Front Axle - 12,000 pounds, with heavy duty front shocks and steering

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Rear Axle - 23,000 pounds, spicer single speed with magnetic traps, with Driver Controlled docking Differential Ratio 5.38 Power Steering - With 18 in. Steering wheel Brakes Service - Air type front and rear 16 Yi in. x 5 in. S-Cam front and 16.5 in. x 7 in. rear. Unit to have ABS full wheel control system. Trailer connections to rear of frame. Air and Electrical with 7-way plug MGM spring type parking brake Dust shields front and rear

Air Compressor - 13 .2 CFM capacity with Automatic bleeders on air tanks Cab - Tilt - hood type conventional, with chrome grille Cab Equipment-

Driver seat (National 2000) air suspension, high back with integral headrest, vinyl isolated, with 2 positions front cushion adjustment, single chamber air lumbar support Cab mounting with Cab Air Suspension. Passenger seat fixed with bottom storage area, air horn, heater and defroster, right and left hand Westcoast style mirrors with spot mirrors, air pressure gauge, water temperature gauge, oil pressure gauge, warning lights and alarm for low oil and water, speedometer, tachometer, volt meter or amp meter, transmission temperature gauge, cab assist handles. Grille, chrome. Air Conditioner - Factory installed. Alternator - 160 AMP minimum Battery - 2 maintenance free 12 volt 1300cca Color - Solid White Engine- Diesel (wet sleeve), minimwn 245 horsepower, 660 lb-ft torque@ 1300 RPM, 2400 RPM governed speed. NOTE: Cummins ISB wi�l not be accepted. Engine Equipment -Cold starting equipment, cruise control, magnetic oil plug, keyed shutdown, heavy duty cooling system, fuel/water separator, single assembly fuel filter spin on type mounted on engine, single stage air cleaner dry type with air restriction gauge, spin on oil filter, wet type sleeved engines, governed for road speeds, horizontal muffler system frame mounted on right side with vertical tailpipe and guard. Provide clean CA -must meet 2010 emission standards. Electrical System -12 volt standard, data link connector for vehicle programming and

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diagnostics in cab, electrical fuses, electric horn, parking light, key operated starter switch, stop, tum, tail and back-up lights, self canceling turn signals, headlight dimmer, front turn signals with auxiliary side turn signals with reflectors, 2 speed windshield wipers with wash and intermittent features, windshield wipers single motor cowl mounted, chassis wiring color coded and numbered, cigar lighter, 7 way trailer connection socket mounted at rear wired for all signal indicators, halogen 2 light headlight system with daytime running lights, factory installed AM/FM stereo with multiple speakers and clock circuit breakers instead of fuses manual reset. Frame -heat treated alloy steel (120,000 PSI Yield) 10.125" x 0.312" Fuel Tank-Minimum 70 gallon aluminum fuel tank, include fuel water separator with heater Springs -front 12,000 lbs. and rear 23,000 lbs, plus auxiliary w 4,500 lbs. Transmission -Automatic (Allison 3500 RDS P) or equivalent, 4th generation controls, 6 speed on/off hwy, Air Shift PTO with double overdrive. Miscellaneous Equipment -Front and rear tow hooks, splash/mud guards, electrically controlled from inside cab load covering tarp system. Tires -Front 11 Rx22.5 16 ply hwy tread Rear 11 Rx22.5 16 ply on/off tread design Spare tire and rim -on/off tread design Rims -Front and Rear 10 hole Disc (steel) Front Bumper -Full width chrome type

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SINGLE AXLE DUMP BODY

Dump Body -Heavy Duty-11 feet in length with full cab shield to protect the chassis and full body welded construction. Sides -Shall be minimum 34 inch height, front bulkhead 50 inches and tailgate 50 inches. Sides, front and tailgate to be constructed of high tensile 10 gauge steel. Body Floor -To be 3/16 inch high tensile steel. Doghouse -Shall be 10 gauge high tensile steel Body -Raised indicator light, hoist control lockout Lights/ Reflectors -to meet FMVSS No. 108. Longitudal -Shall be minimum 5 inch channel main frame. Crossmembers -Shall be 3 inch channel skip welded on 12 inch centers Vertical Side Braces -Shall be 6 inch wide each side Top Rail -Shall be 3 inch tubing/dirt shredding lower outer rub rails Tarp System -Shall be electric, with aluminum arms with in-cab control for roll-up tarp system. A Heavy Duty PTO -Shall be furnished with an in-cab control tower that can incorporate spreader control as well. Unit -Shall have a 12 inch asphalt skirt, mud flaps, and back-up alarm Unit -Shall be painted black and installed completely. Hoist-Shall be a VENCO VC476-ES underbody hoist/saddle/tank and pump control if alternate hoist is furnished it must have equivalent NTEA rating for this size body or greater. Unit-Must be equipped with a body safety prop and meet all OSHA standards. Tailgate -Must be equipped with chains long enough to lay tailgate down from top. Hydraulic System -Tandem, gear type pump, 2000 PSI rated, mounted directly to PTO. Pump section for dump body to be rated for 22 GPM; pump section for spreader to be rated for 18 GPM; both at 1800 RPM.

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Pump - Shall be air shifted, plus have control valve for flow metering and easy operator access. Spreader Section on hydraulic pump - to be equipped with dual full pressure in-cab controls, pressure relief for both sections set at 1500 PSI. To include dual remote hydraulic outlets and quick connects located at the back end of the truck frame, attached to pintle hook backing plate. A Hydraulic Reservoir - 30 gallon capacity shall be mounted to the truck frame, complete with replaceable cartridge type return line oil filter. ALL BIDDERS ARE TO STATE THE APPROXIMATE DELIVERY DATE OF THE COMPLETE UNITS AND THE STANDARD WARRANTY PROVIDED BY THE MANUFACTURER. Warranty and Technical/Parts Manual

Standard written warranty shall be provided to cover entire units. All warranties shall start from date of delivery. Two (2) service, repair and parts manuals (for each unit) shall be provided. CD-ROM/DVD's if available. Must be delivered to:

Shelby County Fleet Services, 6200 Haley Road, Memphis, TN 38134

SCOPE OF WORK

SCOPE:

It is the intent of this bid to obtain firm prices on the listed vehicles/equipment for the Shelby County Roads, Bridges, and Engineering for immediate purchase. Any exceptions to the detailed specifications must be clearly spelled out at the time of bid and listed in the response notes as an attachment. New and Unused 2018 Vehicle/Equipment as follows: the two (2) 2018 Single Axle Dump Trucks with a central hydraulic system to operate a hoist and a material spreader/spinner that would be attached in the bed. These two (2) units, including all necessary equipment shall be furnished complete and ready for use. All parts not specifically mentioned, but which are required for a complete unit shall be furnished according to the current standard design of the manufacturer. Bidder must be an authorized sales, parts, and service facility for the make that it represents. Bidders must be capable of performing warranty work on all truck components. Bidders must carry an adequate inventory of parts necessary for making repairs. Bidders shall certify that the equipment proposed is in compliance with all OSHA requirements when manufactured. Two (2) Parts and Service Manuals to be supplied with unit.

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DEPARTMENT:

Shelby County Roads, Bridges, and Engineering Department. The area outlined above and any Federal, State, County, or other local Municipalities shall be able to participate in this purchase as long as the specifications/terms/delivery requirements are the same as outlined herein.

CONDITION:

Vehicle/Equipment shall be the latest year model new and unused. STANDARD EQUIPMENT:

The Specifications contained in this bid are considered the standard base vehicle/equipment for this bid. The standard base vehicle/equipment may include items that are not included as standard by the manufacturer. When these items are included in the Specifications, the bidder must include the cost of these items in the bid. PRE-DELIVERY SERVICING:

The dealer shall service and adjust vehicle/equipment for operational use to include as a minimum the following, if applicable: 1. Focus Light 2. Tuned Engine 3. Check Electrical, Braking and Suspension System 4. Charge Battery 5. Align Front Ends 6. Balance All Wheels 7. Service Cooling System with Permanent Type Anti-Freeze and Summer Coolant for - 20° F 8. Service Windshield Worker Reservoir with Water and Appropriate Additives 9. Complete Lubrications 10. Fill crankcase with Oil

7. DEMONSTRATION OF GOODS/SERVICES

N/A

8. EQUAL / EQUIVALENT PRODUCTS

When applicable, Bidders may bid “or equal” or equivalent product (s) to the product specified. However, it must be stated that the Good/Service bid are either considered to be

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equal or equivalent to the specifications. Bidders shall provide pertinent information in the bid response notes setting out and describing the goods/services being offered if bid is for an “or equal” Good/Service.

The Administrator of Purchasing, with the requesting Department, reserves the right to

approve as an equal, or to reject as not being equal, any Good/Service the Bidders propose to furnish which contains minor variations from specifications, but may comply herewith.

The Bidder shall abide by and comply with the true intent of the specifications and not take

advantage of any unintentional errors or omissions, but shall fully complete every part as the true intent and meaning of the specifications.

Changes to the bid specifications are not valid unless authorized in writing by the Shelby County Purchasing Department. Any “equal or equivalent” (OUTSIDE of the specifications) shall be stated ONLY in the bid. Goods/services exceeding specifications will be considered as meeting specifications.

Shelby County Government will not accept alternate bids (except if Construction) and/or

which are not equal in specifications.

9. DEVIATIONS TO SPECIFICATIONS

These specifications are intended as minimum requirements. However, it is recognized that each manufacturer has special features that make his equipment unique. Therefore, all bids will be considered, but every bidder must state, in detail where his equipment fails to meet these specifications. It is the intention of the Buyer to purchase quality products and not necessarily the products with the lowest initial cost. The County reserves the right to reject any and all bids. Shelby County Government will not accept alternate bids (except if Construction) and/or

which are not equal in specifications.

10. SPECIAL PACKAGING

N/A

11. DELIVERIES / F.O.B. POINT

Unless otherwise specified, all deliveries are to be F.O.B. Destination, Freight prepaid, Inside/Inplace to the ordering department per their instructions.

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All invoices, vehicle/equipment, and all documents pertinent to the vehicle/equipment shall be delivered to:

Shelby County Fleet Services Department 6200 Haley Road Memphis, TN 38134

Vehicle/Equipment should be delivered within 90 days after receipt of our written purchase

order.

Refer to Inspection section.

12. LOCATIONS

Local presence

All bidders are required to have an adequate service organization on a local basis. Multiple locations

N/A

13. RIGHTS OF INSPECTION AND/OR SAMPLING

Inspections & Approvals

Any/all items delivered as a result of award of this bid shall be new and unused and have been completely serviced by the successful bidder and be ready for inspection at the time of delivery. Final acceptance will be determined by inspection of items by Shelby County. Samples

N/A

14. FIRM PRICES / DISCOUNTS / QUANTITIES / RENEWALS

Vendors shall complete and sign their Quotation/Bid Response Form (refer to Section IV)

Firm Prices & Renewal(s)

Unless otherwise specified, all prices are to be firm for a period of not less than 180 days from the date of the bid opening. Bidder shall indicate time period (in days after date of bid opening) their prices shall remain firm. Shelby County Government reserves the right to reject any increase and cancel this

bid/agreement if the price increase is considered prohibitive.

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Discounts

However, the successful Vendor shall be required to give Shelby County Government the benefit of any general price reduction at any time during the term of this award.

It is also the intent of this bid to obtain any discounts not specifically itemized in this bid. Bidders must include/specify a discount percentage off of current year pricing and provide justifications, when appropriate.

Quantities & Replacements

There are no guaranteed quantities and/or dollar amounts which will be purchased against this bid.

Shelby County Government reserves the right to purchase additional equipment from this bid at the prices offered in each successful vendor’s bid.

15. PAYMENT SCHEDULE

Prompt payment discount shall be considered a cost factor in this bid. Invoices shall be paid thirty (30) days after receipt of correct invoices. Invoices shall be sent directly Fleet Services.

16. AWARDS (full or partial)

Shelby County Government reserves the right to reject all bids, or any part thereof, waive any informality in the bids to make award in the best interest of the County, and to request additional information, an interview, a demonstration of the bid goods/services proposed. Shelby County Government reserves the right to award this bid on the basis of individual goods/services, groups of goods/services or the entire list of goods/services, whichever is in the best interest of the County.

All decisions are made at the discretion of the County, including the Mayor and the Administrator of Purchasing (and the Board of Commissioners, if above $50,000). The proposers whose proposals do not meet the mandatory minimum requirements will be considered non-responsive, and not eligible for Department evaluation nor award. The proposers whose proposals do not meet the Department specifications/requirements will not be eligible for award. The intent of Shelby County Government is to award this bid based on a competitive selection of responsive proposals received, i.e. to the overall responsive low Bidder(s) meeting specifications. The evaluation/selection process may exceptionally include a request for additional information (from Purchasing only), to support the written proposal. After evaluation of the proposals and selection of the successful Vendor(s), they will be notified in writing.

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The contents of the proposal of the successful proposer will become contractual obligations and failure to accept these obligations in a contractual agreement may result in cancellation of the award. The County reserves the right to negotiate any portions of the successful proposer’s fees, scope of work or utilize their own resources for such work.

No Purchase Order against this bid until formal Award and/or signed Contract.

17. CONTRACT / AWARD LETTER / CANCELLATION

A contract will NOT be required. A purchase order(s) will be issued to the successful vendor(s). Shelby County Government reserves the right to cancel this bid/proposal for failure to provide goods/services as per the bid specifications. Cancellation will be subject to not less than a thirty (30) day notification.

18. ORDERS

Ordering of goods/services - by the County

N/A Receiving orders and sending invoices – by the Vendor

All invoices and documents pertinent to the vehicle/equipment shall be delivered to:

Shelby County Fleet Services Department 6200 Haley Road Memphis, TN 38134

All paperwork must be made out to: Shelby County Government, 160 North Main Street, Memphis, TN 38103. Accepting orders - by the County

N/A

19. ADDITIONAL INFORMATION FROM THE BIDDER

Bidders are encouraged to submit additional information which they feel might be useful to the County in evaluating their bid; however, Shelby County Government reserves the right to accept or reject for consideration, during evaluation of bids, any minor variations.

Any additional information (OUTSIDE of the specifications) shall be stated ONLY in the bid response notes.

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Shelby County Government will not accept alternate bids (except if Construction) and/or

which are not equal in specifications.

20. LOSB and M/WBE

There is no goal established for this particular bid, due to lack of LOSB/MWBE availability. However, Shelby County Government welcomes and encourages LOSB/MWBE participation: LOSB or MWBE primes will still receive preferences, even if no required goal on this bid. Should there be mention of a LOSB/MWBE goal or requirements in any other section of this bid, please DISREGARD.

21. QUESTIONS / INQUIRIES

All correspondence and questions concerning the Sealed Bid are to be submitted IN WRITING to:

Sonja Worthy, Buyer Sonja.worthy@shelbycountytn.gov

Shelby County Government Purchasing Department

160 N. Main Street, 9th Floor, Suite 900 Memphis, TN 38103

Questions should reference the Sealed Bid number & title, section of the Sealed Bid to which the questions pertain and all contact information for the person submitting the questions.

All written questions submitted by the deadline indicated above will be answered and posted on the County’s website at http://www.shelbycountytn.gov/3243/Bids-Listing mostly within forty-eight (48) hours.

IN ORDER TO PREVENT AN UNFAIR ADVANTAGE TO ANY RESPONDENT, VERBAL QUESTIONS WILL NOT BE ANSWERED.

Please be aware that contact with any other personnel (other than the person clearly identified in this document) within Shelby County regarding this Sealed Bid may disqualify your company from further consideration, including NO COMMUNICATION BETWEEN THE

VENDORS AND THE SCG DEPARTEMENT between now and award.

These guidelines for communication have been established to ensure a fair and equitable process for ALL interested vendors.

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SEALED BID#: I000502

DUE DATE: 4/09/18 BUYER: S. Worthy

SHELBY COUNTY PURCHASING DEPARTMENT ROOM 900, 160 NORTH MAIN STREET

MEMPHIS, TENNESSEE 38103 PHONE (901) 222-2250

NOTE: RETURN ONLY THIS SECTION WHEN SUBMITTING YOUR BID

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DRUG-FREE WORKPLACE AFFIDAVIT

STATE OF__________________

COUNTY OF_________________

The undersigned, principal officer of _____________________________, an employer of five (5) or more

employees contracting with _______________County government to provide goods and/or services states under oath

as follows:

1. The undersigned is a principal officer of____________________________________________ (hereinafter

referred to as the “Company”), and is duly authorized to execute this Affidavit on behalf of the Company.

2. The Company submits this Affidavit pursuant to T.C.A. § 50-9-113, which requires each employer with no less

than five (5) employees receiving pay who contracts with the state or any local government to provide goods

and/or services to submit an affidavit stating that such employer has a drug-free workplace program that

complies with Title 50, Chapter 9, of the Tennessee Code Annotated.

3. The Company is in compliance with T.C.A.~ 50-9-113. Further affiant saith not.

Principal Officer (Name and Signature) ______________________________________________

STATE OF_______________________

COUNTY OF____________________

Before me personally appeared_________________ with whom I am personally acquainted (or proved to me on the basis

of satisfactory evidence), and who acknowledged that such person executed the foregoing affidavit for the purposes

therein contained. Witness my hand and seal at office this _____ day of , 20______ Notary Public: __________________________

My Commission Expires: _______________

NOTE: if less than five (5) employees, pls mark n/a and sign/submit with your proposal

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Code of Ethics Section 18-59

SHELBY COUNTY GOVERNMENT

GRATUITY DISCLOSURE FORM

(NO COPIES ACCEPTED)

INSTRUCTIONS: This form is for all individuals receiving any Shelby County Government contract, subcontract, land

use approval or financial grant of money to report any gratuity that has been given, directly or indirectly, to any elected

official, employee or appointee (including their spouse and immediate family members) who is involved in the decision

regarding the contract, land use approval, or financial grant of money.

1. COMPANY/VENDOR NAME

2. DATE OF GRATUITY

3. NATURE AND PURPOSE OF THE GRATUITY

4. NAME OF THE OFFICIAL, EMPLOYEE, APPOINTEE, OR FAMILY MEMBER WHO RECEIVED

THE GRATUITY

5. NAME OF THE PERSON OR ENTITY THAT PROVIDED THE GRATUITY

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6. ADDRESS OF THE PERSON OR ENTITY THAT PROVIDED THE GRATUITY

7. DESCRIPTION OF THE GRATUITY

8. COST OF THE GRATUITY (If cost is unknown and not reasonably discernible by the person giving the gratuity, then the person giving the gratuity shall report a good faith estimate of the cost of the gratuity.)

9. The information contained in this Gratuity Disclosure Form, and any supporting documentation or materials referenced herein or submitted herewith, is true and correct to the best of my knowledge, information and belief and I affirm that I have not given, directly or indirectly, any gratuity to any elected official, employee or appointee (including their spouse and immediate family members) that has not been disclosed and I affirm that I have not violated the provisions of the Shelby County Code of Ethics.

Signature Date

Print Name

A copy of your completed form will be placed on the Shelby County Internet website.

A copy of your signature will not be accepted. Form must have original signatures.