Supplier Response Form

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SUBCONTRACTOR/SUPPLIER LISTING

(Miami-Dade County Code Sections 2-8.1, 2-8.8 and 10-34)

 

 

Name of Bidder/Proposer:   *  FEIN No.

 

In accordance with Sections 2-8.1, 2-8.8 and 10.34 of the Miami-Dade County Code, this form must be submitted as a condition of award by all Bidders/Proposers on County contracts for purchase of supplies, materials or services, including professional services which involve expenditures of $100,000 or more, and all Proposers on County or Public Health Trust construction contracts which involve expenditures of $100,000 or more.  The Bidder/Proposer who is awarded this contract shall not change or substitute first tier subcontractors or direct suppliers or the portions of the contract work to be performed or materials to be supplied from those identified, except upon written approval of the County.  The Bidder/Proposer should enter the word "NONE" under the appropriate heading of this form if no subcontractors or suppliers will be used on the contract and sign the form below.

 

I In accordance with Ordinance No. 11-90, an entity contracting with the County shall report the race, gender and ethnic origin of the owners and employees of all first tier subcontractors/suppliers.  In the event that the recommended Bidder/Proposer demonstrates to the County prior to award that the race, gender, and ethnic information is not reasonably available at that time, the Bidder/Proposer shall be obligated to exercise diligent efforts to obtain that information and provide the same to the County not later than ten (10) days after it becomes available and, in any event, prior to final payment under the contract.

 (Please duplicate this form if additional space is needed.)

Business Name and Address of First Tier Direct Supplier

Principal Owner

Supplies/ Materials/ Services to be Provided by Supplier

Principal Owner

(Enter the number of male and female owners by race/ethnicity)

Employee(s)

(Enter the number of male and female employees and the number of employees by race/ethnicity)

M

F

White

Black

Hispanic

Asian/Pacific Islander

Native American/ Native Alaskan

Other

M

F

White

Black

Hispanic

Asian/Pacific Islander

Native American/ Native Alaskan

Other

Business Name and Address of First Tier Subcontractor/ Subconsultant

Principal Owner

Scope of Work to be Performed by Subcontractor/ Subconsultant

Principal Owner

(Enter the number of male and female owners  by race/ethnicity)

Employee(s)

(Enter the number of male and female employees and the number of employees by race/ethnicity)

M

F

White

Black

Hispanic

Asian/Pacific Islander

Native American/ Native Alaskan

Other

M

F

White

Black

Hispanic

Asian/Pacific Islander

Native American/ Native Alaskan

Other

 

 

Mark here if race, gender and ethnicity information is not available and will be provided at a later date.  This data may be submitted to contracting department or on-line to the Small Business Development of the Internal Services Department at http://www.miamidade.gov/business/business-development-contracts.asp. As a condition of final payment, Bidder/Proposer shall provide subcontractor information on the Subcontractor Payment Report Sub 200 form which can be found at http://www.miamidade.gov/business/library/forms/subcontractors-payment.pdf.

 

 

 

I certify that the representations contained in this Subcontractor/Supplier listing are to the best of my knowledge true and accurate.

 * 

 * 

 * 

 * 

Signature of Bidder/Proposer

Print Name

Print Title

Date

 

SUB 100 Rev. 1/14



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