205-26 Exhibit.pdf

Person or Entity law, rule or: covering. damages,: appropriate: and tions, secking | om} suspension of the party I certify, pursuant to Public Law 2012, c. 25, that neither the person or entity listed above, nor any parent entity, subsidiary, or affiliate thereof is listed on the N.J. Department of the Treasury's list of entities determined to be engaged in prohibited activities in Iran pursuant to P.L. 2012, c. 25 ("Chapter 25 List"). Lfurther certify that I am the person listed above, or I am an officer or representative of the entity listed above and am authorized to make this certification on its behalf. I will skip Part 2 and sign and complete the Certification below. Tam unable to certify as above because the person or entity and/or a parent entity, subsidiary, or affiliate thereof is listed on the N.J. Department of the Treasury's Chapter 25 list. I will provide a detailed, accurate and precise description of the activities in Part 2 below sign and complete the Certification below.

a detailed, accurate \ idiaty, or affiliate theres ivates in | on additional sheets pr i (ope begga denen ‘gation from the date of this certification” = ce to Township of West Orange to notify the any changes to the answers. “make =a false bj cri ‘West Orange: = eontract(s) rest Full Name . (Print) Title Signature Date

ih, hereby represent and state that the foregoing infor Anowledge, are true and complete. I altest that 1 an above-) referenced [Person oF entily, t F Orange i is: relying on the information conti ing obligation from the date of this cert ‘owaship of West alee fo noti Ue the To BE being duly sworn upon i atiachi ents fhere, lo the bes iy, greemeiii(s) with the Township of ay declare any contiact(s) resulting ‘ Title (Print) Signature Date

EXHIBIT A MANDATORY EQUAL EMPLOYMENT OPPORTUNITY LANGUAGE N.J.S.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 shall 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 places, 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 applicable 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 subcontractor 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. 10:5-31 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. 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 orientation, 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 execution of a goods and services contract, one of the following three documents: 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 NJAC. 17:27,

STATEMENT OF OWNERSHIP DISCLOSURE NLJS.A. 52:25-24.2 (P.L. 1977, c.33, as amended by P.L. 2016, c.43) This statement shall be completed, certified to, and included with all bid and proposal submissions. Failure to submit the required information is cause for automatic rejection of the bid or proposal. Name of Organization: Organization Address: Part I Check the box that represents the type of business organization: Dsote Proprietorship (skip Parts Il and Ill, execute certification in Part IV) DA non-profit Corporation (skip Parts II and III, execute certification in Part IV) Oo For-Profit Corporation (any type) oO Limited Liability Company (LLC) | Partnership | Limited Partnership | Limited Liability Partnership (LLP} O Other (be specific): Part II who own 10 percent or more of its stock, of any class, or of all individual partners in the ql partnership who own a 10 percent or greater interest therein, or of all members in the limited liability company who own a 10 percent or greater interest therein, as the case may be, (COMPLETE THE LIST BELOW IN THIS SECTION) | The list below contains the names and addresses of all stockholders in the corporation OR Oo No one stockholder in the corporation owns 10 percent or more of its stock, of any class, or no individual partner in the partnership owns a 10 percent or greater interest therein, or no member in the limited liability company owns a 10 percent or greater interest therein, as the case may be. (SKIP TO PART IV) Please attach additional sheets if more space is needed): Name of Individual or Business Entity Address

Part TT piscLosure OF 10% OR GREATER OWNERSHIP IN THE STOCKHOLDERS, PARTNERS OR LLC MEMBERS LISTED IN PART II lfa bidder has a direct or indirect parent entity which is publicly traded, and any person holds a 10 percent or greater beneficial interest in the publicly traded parent entity as of the last annual federal! Security and Exchange Commission (SEC) or foreign equivalent filing, ownership disclosure can be met by providing links to the website(s) containing the last annual filing(s) with the federal Securities and Exchange Commission (or foreign equivalent) that contain the name and address of each person holding a 10% or greater beneficial interest in the publicly traded parent entity, along with the relevant page numbers of the filing(s) that contain the information on each such person. Attach additional sheets if more space is needed. Website (URL) containing the last annual SEC (or foreign equivalent} filing Page #’s Please list the names and addresses of each stockholder, partner or member owning a 10 percent or greater interest in any corresponding corporation, partnership and/or limited liability company (LLC) listed in Part Il other than for any publicly traded parent entities referenced above. The disclosure shall be continued until names and addresses of every noncorporate stockholder, and individual partner, and member exceeding the 10 percent ownership criteria established pursuant to NJ,S.A. 52:25-24.2 has been listed. Attach additional sheets if more space is needed. Stockholder/Partner/Member and Address Corresponding Entity Listed in Part I] Part IV Certification 1, being duly sworn upon my oath, hereby represent that the foregoing information and any attachments thereto to the best of my knowledge are true and complete. | acknowledge: that | am authorized to execute this certification on behalf of the bidder/proposer; that the Township of West Orange Is relying on the information contained herein and that | am under a continuing obligation from the date of this certification through the completion of any contracts with Township of West Orange to notify the Township of West Orange in writing of any changes to the information contained herein; that | am aware that it is a criminal offense to make a false statement or misrepresentation in this certification, and if | do so, | am subject to criminal prosecution under the law and that

herein; that | am aware that it is a criminal offense to make a false statement or misrepresentation in this certification, and if | do so, | am subject to criminal prosecution under the law and that it will constitute a material breach of my agreement(s) with the, permitting the Township of West Orange to declare any contract(s} resulting from this certification void and unenforceable.

Full Name (Print): Title: Signature: Date: REQUIRED EVIDENCE AFFIRMATIVE ACTION REGULATIONS NJ. S.A. 10:5-31, et seq. (NJ.A. C. 17:27) ifawarded a contract, the Bidder will be required to comply with the requirements of NLLS.A. 10:531, et seq., and NLA.C_ 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 oz sanctioned affirmative action program; or 2. A Certificate of Employee Information Report Approval issued in accordance with N,.A.C. 17:27-4; ot 3. An initial Employee Information Report consisting of forms provided by the Affirmative Action Office and completed by Contractor in accordance with NJ.A.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 fornis provided by the Affirmative Action Office and completed by Contractor in accordance with N.[A.C. 17:27-7. Biddets ate referred to the Bidder's Information Section of the Bid Packet for a further desctiption of the above requirements. NO BIDDER MAY BE ISSUED A CONTRACT UNLESS THEY COMPLY WITH THE AFFIRMATIVE ACTION REGULATIONS OF NLS.A. 10:5-31, ct seq. ‘The following questions must be answered by all Bidders: 1 Do you have a federally-approved or sanctioned Affirmative Action Program? Yes (If yes, submit 4 copy of such approval.) No 2. Do you have a State Certificate of Employee Infozmation Report approval? Yes {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 NJS.A. 10:5-31, et seq., and agrees to fumish the requited documentation pursuant to the law. COMPANY: NAME: SIGNATURE: TITLE: NOTE: A bid must be tejected as non-responsive if a Bidder fails to comply with requirements of NJS.A. 10:5-31, et seq,, within the time frame stipulated.