320-22 Exhibit A.pdf

art 2: PLEASE PROVIDE FURTHER INFORMATION RELATED TO INVESTMENT ACTIVITIES IN IRAN Continued... You must provide a detalled, 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: Certification: |, being duly sworn upon my oath, hereby represent and state that the foregoing Information and any attachments thereto to the best of my knowledge are true and complete. | attest that | am authorized to execute this certification on behalf of the above referenced person or entity. 1 acknowledge that the Township of West Page | 17

Orange, State of New Jersey Is relying on the Information contained herein and thereby acknowledge that |am under acontinuing obligation from the date of this certification through the completion of any contracts with the Township to notify the Township in writing of any changes to the answers of information contained herein, | acknowledge that {am aware that It Is a criminal offense to make a false statement or misrepresentation in this certification, and if | do so, | recognize that | am subject to criminal prosecution under the law and that it will also constitute a material breach of my agreement(s) with the Township of West Orange, State of New Jersey and that the Township at at Its - ~ —option may declare any contract(s)-resulting from this bole and unenforceable, —- Full Name (Print); Robert W. Bohny Signature: ono Fiile fesident becerber 1,.2022.\ Fh =a == ===pater a = a al = Please check appropriate boxes on this form. Page | 18

EXHIBIT A MANDATORY EQUAL EMPLOYMENT OPPORTUNITY LANGUAGE N.J.5.A. 10:5-31 et seq, (P.L. 1975, C. 127} NJAC, 17:27 GOODS, PROFESSIONAL SERVICE AND GENERAL SERVICE CONTRACTS During the performance of this contract, the contractor agrees as follows: The contractor or subcontractor, where applicable, will not discriminate against any employee or applicant for employment because of age, race, creed, color, national origin, ancestry, marital status, affectional.or sexual orientation, gender identity or expression, disability, nationality or sex-Except with respect to affectional or sexual orientation and gender identity or expression, the contractor will ensure that equal employment opportunity is afforded to such applicants in recruitment and employment, and that employees are treated during employment, without regard to their age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex. Such equal employment opportunity shail include, but not be limited to the following: employment, upgrading, demotion, or transfer; recruitment or recruitment advertising; layoff or termination; rates of pay or other forms of compensation; and selection for training, including apprenticeship. The contractor agrees to post in conspicuous piaces, available to employees and applicants for employment, notices to be provided by the Public Agency Compliance Officer setting forth provisions of this nondiscrimination clause. The contractor or subcontractor, where appticable will, in all solicitations or advertisements for employees placed by or on behalf of the contractor, state that all qualified applicants will receive consideration for employment without regard to age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex. The contractor or stibcontractor will send to each labor union, with which it has a collective bargaining agreement, a notice, to be provided by the agency contracting officer, advising the labor union of the contractor's commitments under this chapter and shall post copies of the notice in conspicuous places available to employees and applicants for employment. The contractor or subcontractor, where applicable, agrees to comply with any regulations

nd shall post copies of the notice in conspicuous places available to employees and applicants for employment. The contractor or subcontractor, where applicable, agrees to comply with any regulations promulgated by the Treasurer pursuant to N.J.S.A, 10:5-34 et seq., as amended and supplemented from time to time and the Americans with Disabilities Act. The contractor or subcontractor agrees to make good faith efforts to meet targeted county employment goals established In accordance with N.J.A.C. 17:27-5.2. The contractor or subcontractor agrees to inform in writing its appropriate recruitment agencies including, but not limited to, employment agencies, placement bureaus, colleges, universities, and labor unions, that it does not discriminate on the basis of age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex, and that it will discontinue the use of any recruitment agency which engages In direct or indirect discriminatory practices, The contractor or subcontractor agrees to revise any of its testing procedures, if necessary, to assure that all personnel testing conforms with the principles of job-related testing, as established by the statutes and court decisions of the State of New Jersey and as established by applicable Federal law and applicable Federal court decisions. Page | 19

In conforming with the targeted employment goals, the contractor or subcontractor agrees to review all procedures relating to transfer, upgrading, downgrading and layoff to ensure that all such actions are taken without regard to age, race, creed, color, national origin, ancestry, marital status, affectional or sexual : orjentation, gender identity or expression, disability, nationality or sex, consistent with the statutes and court ! decisions of the State of New Jersey, and applicable Federal law and applicable Federal court decisions. ‘ The contractor shall submit to the public agency, after notification of award | but prior to e: execution ofa a ~~ goodsand services contract, ore of the following three documents: - - Te H Letter of Federal Affirmative Action Plan Approval ~ Certificate of Employee information Report — Employee Information Report Form AA302 (electronically provided by the Division and distributed to the public agency through the Division’s website at www.state.nj.us/treasury/contract_compliance) The contractor and its subcontractors shall furnish such reports or other documents to the Division of Public Contracts Equal Employment Opportunity Compliance as may be requested by the office from time to time in order to carry out the purposes of these regulations, and public agencies shall furnish such information as may be requested by the Division of Public Contracts Equal Employment Opportunity Compliance for conducting a compliance investigation pursuant to Subchapter 10 of the Administrative Code at NJ.A.C, 17:27. | i f f Page | 20

STOCKHOLDER DISCLOSURE CERTIFICATION | 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. x | certify that no one stockholder owns 10% or more of the issued and outstanding stock of the undersigned. EASE CHECK TYPE OF BUSINESS ORGANIZATION: ' Partnership Limited Partnership Limited Liability Corp Subchapter $ Corp _ PLEASE CHECK APPROPRIATE BOXES AND SIGN BELOW Name: Home Address: Stockholders Name: Robert W. Bohny i Home Address: Name Richard T. Bohny Home Address: ry Name: Jeffrey M. DeJesus Home Address: Si Robert W. Bohny, President Print Name & Title : hoi Owner or Rephese ntative Signature NQTORY PUBLIC 2022. i ig roxell Notary Public onSaeatens | Ission No, 2338 | My Commission Expires danvany 8, 2026 Page | 21

REQUIRED EVIDENCE AFFIRMATIVE ACTION REGULATIONS NJ. S.A. 10:5-31, et seq. (NLA. C. 17:27) Ifawarded a contract, the Bidder will he required to comply with the requirements of N.L.S.A. 10:534, et seq., and NJAC, 17:27, Within five (5) days after receipt of the notification of intent to award the contract, the Bidder shall present one of the following: 1. Appropriate evidence that the Contractor is operating under an existing federally approved or sanctioned aa ae os - -afficmative-action-programyor - ~~ - - 2. A Certificate of Employee Information Repost Approval issued in accordance with MN LAC. 1127-+ 43 oF 3. An initial Himployee 1 Information Report consisting of forms provided by the Affirmative Action Office and completed by Contractor in accordance with N,LA.C. 17:27-4, ‘The Bidder must submit no later than three (3) days after the signing of the Contract an Initial Project Manning Table consisting of forms provided by the Affirmative Action Office and completed by Contractor in accordance with NL.LAG, 17:27-7. Bidders are referred to the Bidder’s Information Section of the Bid Packet for a further description of the above requirements. NO BIDDER MAY BE ISSUED A CONTRACT UNLESS THEY COMPLY WITH THE AFFIRMATIVE ACTION REGULATIONS OF NJS.A. 10:5-31, et seq, ‘The following questions must be answered by all Bidders: 1. Do you have a federally-approved or sanctioned Affirmative Action Program? Yes (Ef yes, submit a copy of such approval.) No 2. Do yow have a State Certificate of Employee Information Report approval? Yes __X {if yes, submit a copy of such approval.) No ‘The undersigned Bidder certifies that he is aware of the commitment to comply with the requirements of NS.A, 10:5-31, et seq., and agrees to furnish the xequited documentation pursuant to the law. company: VCl Emergency Vehicle Specialists LLC ame; Robert W. Bohny SIGNATURE: Kiotor-\ TITLE: President NOTE: A bid must be rejected s) non-responsive if a Bidder fails to comply with requirements of NJ,S.A. 10:5-31, et seq., within the time frame stipulated. Page | 22

TOWNSHIP OF WEST ORANGE ACKNOWLEDGMENT OF RECEIPT OF ADDENDA The undersigned Bidder hereby acknowledges receipt of the following addenda: Piease assign the number, date and initial. __. Addendum Number _.. .. _Pated_ _ Acknowledge Receipt (initial) No addenda was/were received. Acknowledged for: VCl Emergency Vehicle Specialists LLC. (Company Name} By: ho (SA (Signature of Althorized Representative) Name: Robert W, Bohny (Print) Title: President Date: December 1, 2022 Page | 23

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 range, or within five (5) years of the e of award for a bid ‘ither directly or indirectly, by the individuals or any of the pal S 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 affillated with an elected official of the Township currently in office. | If you have NOT made any contributions within the scope of Section 2-68.1, as set forth above, please X the line to the right. | hereby certify under penalty of peyjury that the information provided herein Is true and accurate to the best of my knowledge, information and belief. The current elected officials of the Township include the following: Mayor Robert D. Parisi; Councilwoman Cindy Matute-Brown, Councilman Bill Rutherford; Councilwoman Susan McCartney, Councilwoman Michelle Casalino; and Councilwoman Tammy Williams. VCI Emergency Vehicle Specialists LLC Copfpany Name Authorized Signathre Robert W. Bohny Printed Name December 1, 2022 Date Page | 24

BIDDER’S CHECK LIST Mandatory Items ‘Business Registration Certification — vy Aus _ BS Stockholders Disclosure Affirmative Action Compliance Notice VR 2) tranian Disclosure Form Yv LA Non-Collusion Affidavit v he Proposal Forrn WA «ue Acknowledgement of Addenda ¥ & fe Political Contribution Form Y hb i Please initial lines. Please provide one additional copy of entire bid package, which can be a USB/Flash Stick END OF BID Page | 25