224-22 Exhibit B-RFQ Licensed Tree Expert for Township Tree Inventory.pdf

TOWNSHIP OF WEST ORANGE Page | 16 AFFIDAVIT OF NON-COLLUSION The undersigned bidder of full age, being duly sworn according to law depose and hereby specifically certifies that: To the best of the bidder's knowledge and belief, the annexed bid proposal for this project has not been prepared in collusion with any other bidder of like item or services and the prices, discounts, terms and conditions thereof have not been directly or indirectly communicated by or on behalf of the bidder to any person other than the recipient of the bid and will not be communicated to any person prior to the official opening of the bid. The bidder fully understands that no premiums, rebates, or gratuities are permitted either with, prior to, or after signing of contract. Any violation will result in cancellation and removal from the bid list. The bidder further certifies that the undersigned has the necessary authority, to sign this stipulation stating that the bidder has not entered into any agreement, or otherwise taken any action in restraint of free competitive bidding in connection with this bid. All references to the bidder are understood to include the undersigned and all principals, partners and officers of the bidder. (Signature) _________________________________ Subscribed and sworn to Before me this day __________________ of 20 __________________ AFFIANT ____________________________ NOTARY PUBLIC OF MY COMMISSION EXPIRES: 20 _________________

TOWNSHIP OF WEST ORANGE Page | 17 INSURANCE REQUIREMENTS AND ACKNOWLEDGEMENT FORM Certificate(s) of Insurance shall be filed with the Municipal Clerk's Office upon award of contract by the Mayor and Township Council. The minimum amount of insurance to be carried by the Professional Service Entity shall he as follows: PROFESSIONAL LIABILITY INSURANCE Limits shall be a minimum of $1,000,000.00 for each claim and $1,000,000.00 aggregate each policy period. Acknowledgement of Insurance Requirement: ___________________________________________ ______________________________________ (Signature) (Date) _______________________________________________________ (Printed Name and Title) This form must be completed, signed and returned with RFQ.

TOWNSHIP OF WEST ORANGE Page | 18 STOCKHOLDER DISCLOSURE CERTIFICATION I certify that the list below contains the names and home addresses of all stockholders holding 10% or more of the issued and outstanding stock of the undersigned. ______ I certify that no one stockholder owns 10% or more of the issued and outstanding stock of the undersigned. _____ PLEASE CHECK TYPE OF BUSINESS ORGANIZATION: Partnership ____ Limited Partnership ____ Limited Liability Corp ____ Corporation ____ Sole Proprietorship ____ Limited Liability Partnership ___ Subchapter S Corp ____ PLEASE CHECK APPROPRIATE BOXES AND SIGN BELOW Name: _______________________________________________ Home Address: ________________________________________ _____________________________________________________ Stockholders Name: ________________________________________________ Home Address: _________________________________________ ______________________________________________________ Name_________________________________________________ Home Address: __________________________________________ _______________________________________________________ __________________________________ ______________________________________ Owner or Representative Signature Print Name & Title NOTORY PUBLIC Sworn before me thisday of ___________20_____.

TOWNSHIP OF WEST ORANGE Page | 19 NON-CONFLICT OF INTEREST CERTIFICATION REQUEST FOR QUALIFICATIONS FOR _____________________________________ (Title of RFQ) The undersigned certifies to the Township of West Orange, County of Essex, State of New Jersey that in performing services to the Township he/she is aware of no circumstance that would constitute a conflict of interest, financial or otherwise, between him/her (or his/her firm) and the interests of the Township. The undersigned certifies that he/she has made a search of his/her firm’s client base and has executed this certification subsequent to such search. The undersigned acknowledges this a continuing certification, and shall remain in effect for the term of the services contained in the solicited request for qualifications. I certify that the foregoing statements made by me are true and accurate to my personal knowledge; I am making this certification in good faith. I am aware that if any of the foregoing statements made by me are false, the Board is free to terminate any professional service agreement entered into with the undersigned and/or his or her firm. Certifying Official: PRINT NAME: _________________________________________________ SIGNED BY: ___________________________________________________ TITLE: ________________________________________________________ DATE: _________________________________________________________

Page | 20 TOWNSHIP OF WEST ORANGE, NEW JERSEY Professional Service Contract Qualification and Costs Submission Form Note: A separate resume can be attached. 1. Please provide the name and address of Names and roles of the individuals who will perform the services and description of their education, municipal experience and experience with projects similar to the services contained herein including their education, degrees and certifications. _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ ______ 2. References and record of success of same or similar service. _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ ______

Page | 21 3. Description of ability to provide the services in a timely fashion (including staffing, familiarity and location of key staff. 4. Cost details, per tree: Authorized Representative___________________________________ (print name) Authorized Representative___________________________________ (signature) Telephone # _______________________________ FAX # _______________________________

Page | 22 Political Contribution Disclosure Statement Pursuant to Chapter 2, Section 68 of the Revised General Ordinances of the Township of West Orange Pursuant to Section 2-68.1 of the Revised General Ordinances of the Township of West Orange, please set forth below all political contributions in cash or in kind of two hundred ($200.00) dollars or more made within five (5) years of the date of acceptance of a proposal for a negotiated contract with the Township of West Orange, or within five (5) years of the notice of award for a bid contract with the Township of West Orange, either directly or indirectly, by the individuals or any of the principals of the business entity completing this form or by the business entity itself, to any elected official of the Township of West Orange currently in office or any political organization affiliated with an elected official of the Township currently in office. The current elected officials of the Township include the following: Mayor Robert D. Parisi; Councilwoman Susan McCartney; Councilwoman Cindy Matute Brown; Councilman Bill Rutherford; Councilwoman Tammy Williams; and Councilwoman Michelle Casalino. Name of Contributor Amount Recipient of Contribution Contribution Date ________________ ________ ___________________ __________ ________________ ________ ___________________ __________ _______________ ________ ___________________ __________ ________________ ________ ___________________ __________ ________________ ________ ___________________ __________ ________________ ________ ___________________ __________ If you have NOT made any contributions within the scope of Section 2-68.1, as set forth above, please indicate here ___________. I hereby certify under penalty of perjury that the information provided herein is true and accurate to the best of my knowledge, information and belief. Signature _________________________________________ Print Name:_________________________________________ Company:______________________________________________ ______________________________________________________

Page | 23 TOWNSHIP OF WEST ORANGE ACKNOWLEDGMENT OF RECEIPT OF ADDENDA The undersigned Bidder hereby acknowledges receipt of the following addenda: Please assign the number, date and initial. Addendum Number Dated Acknowledge Receipt (Initial) _____________ ____________ _______________ _____________ ____________ _______________ _____________ ____________________________ _____________ ____________________________ No addenda was received. Acknowledged for: ______________________________________________________ (Company Name) By: _________________________________________ (Signature of Authorized Representative) Name: _______________________________________ (Print) Title: ________________________________________ Date: ________________________________________

Page | 24 TOWNSHIP OF WEST ORANGE DISCLOSURE OF INVESTMENT ACTIVITIES IN IRAN Proposer: _____________________ Pursuant to Public Law 2012, c. 25, any person or entity that submits a bid or proposal or otherwise proposes to enter into or renew a contract must complete the certification below to attest, under penalty of perjury, that the person or entity, or one of the person or entity’s parents, subsidiaries, or affiliates, is not identified on a list created and maintained by the New Jersey Department of the Treasury as a person or entity engaging in investment activities in Iran. If the Director finds a person or entity to be in violation of the principles which are the subject of this law, s/he shall take action as may be appropriate and provided by law, rule or contract, including but not limited to, imposing sanctions, seeking compliance, recovering damages, declaring, declaring the party in default and seeking debarment or suspension of the person or entity. I certify, pursuant to Public Law 2012, c. 25, that the person or entity listed above for which I am authorized to submit a proposal: Must check appropriate boxes Is not providing goods or services of $20,000,000 or more in the energy sector of Iran, including a person or entity that provides oil or liquefied natural gas tankers, or products used to construct or maintain pipelines used to transport oil or liquefied natural gas, for the energy sector of Iran, and Is not a financial institution that extends $20,000,000 or more in credit to another person or entity, for 45 days, or more, if that person or entity will use the credit to provide goods or services in the energy sector in Iran. In the event that a person or entity is unable to make the above certification because it or one of its parents, subsidiaries, or affiliates has engaged in the above referenced activities, a detailed, accurate and precise description of the activities must be provided in part 2 below to the New Jersey Turnpike Authority under penalty of perjury. Failure to provide such will result in the proposal being rendered as non- responsive and appropriate penalties, fines and/or sanctions will be assessed as provided by law. Part 2: PLEASE PROVIDE FURTHER INFORMATION RELATED TO INVESTMENT ACTIVITIES IN IRAN You must provide a detailed, accurate and precise description of the activities of the proposer, or one of its parents,

t 2: PLEASE PROVIDE FURTHER INFORMATION RELATED TO INVESTMENT ACTIVITIES IN IRAN You must provide a detailed, accurate and precise description of the activities of the proposer, or one of its parents, subsidiaries or affiliates, engaging in the investment activities in Iran outlined above by completing the boxes below. Name: ___________________________________ Relationship to Proposer: _____________________ Description of Activities: ______________________________________________________________________ ______________________________________________________________________ Duration of Engagement: __________________ Anticipated Cessation Date: _____________________ Proposer Contact Name: _________________________ Contact Phone Number: __________________