Township Council Meeting — Packet

BIDDER’S CHECK LIST Business Registration Certification Statement of Ownership Affirmative Action Compliance Notice (required) Iran Investment Activities Non-Collusion Affidavit Proposal Form Acknowledgement of Addenda Political Contribution Form Bid Deposit (10% of bid not to exceed $20,000.00) required K KNAAKABS BIS BID -CHECIE Consent of Surety if providing a Bid Bond Americans with Disabilities Act of 1990 Acknowledgement of Insurance KK CERTIFICATION OF NON-INVOLVEMENT IN PROHIBITED ACTIVITIES IN RUSSIA OR BELARUS Please provide one additional copy of entire bid package which can be on a usb/flash stick. Please do not submit bids double sided.

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STATEMENT OF OWNERSHIP DISCLOSURE NJ.S.A. 52:25-24.2 (P.L. 1977, ¢.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: STCGLLING SECTS = ) bs a5 UEZLOALAN peg PaagTvTus AvE ALT O7IUY Organization Address: Part | Check the box that represents the type of business organization: Dsote Proprietorship (skip Parts Il and lil, execute certification in Part IV} Dnon-Prosit Corporation (skip Parts {I and Ill, execute certification in Part IV) oO For-Profit Corporation (any type} Limited Liability Company (LLC) Oo Partnership Oo Limited Partnership oO Limited Liability Partnership (LLP) oO Other (be specific): Part ll fa The list below contains the names and addresses of all stockholders in the corporation who own 10 percent or more of its stock, of any class, or of all individual partners in the 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) OR oO No one stockholder in the corporation owns 10 percent or more of its stock, of any class, of 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 x se , Venera Cary BoerT6s Saf’| (SS PEHaTPTORS ACK A ape4yY i “uo VERY ALA VINCERT Vecl 54 MSS Dpoweter Ave ny a7ty

Part Ill DISCLOSURE OF 10% OR GREATER OWNERSHIP IN THE STOCKHOLDERS, PARTNERS OR LLC MEMBERS LISTED IN PART Il If a 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 1! other than for any publicly traded parent entities referenced above. The disclosure shall be continued until names and addresses of every non-corporate 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 Il YBIEMGA CARY Bootes soP| pss pometew nus Am epee pe UY ERAN ; Vingcen7T vec $e LSS POVaPT Ow! AUF pepe Part IV Certification |, 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

h 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, lam subject to criminal prosecution under the Jaw 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. 23|Page

Full Name (Print): Bary PBortse Title: | 0 y -awAy ee Signature: Ee b45_— Date: Y~1G- 2 a 24| Page ~~ 7

(REVISED 4/10) EXHIBIT A MANDATORY EQUAL EMPLOYMENT OPPORTUNITY LANGUAGE N.J.S.A. 10:5-31 et seq. (PL. 1975, C. 127) NJ.A.C. 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 tespect 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

r 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 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. (continued) The contractor or subcontractor agrees to infarm in writing its appropriate recruitment agencies including, but not limited to, employment agencies, placement bureaus, colleges, universities, and iabor 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

REQUIRED EVIDENCE AFFIRMATIVE ACIION REGULATIONS NJ. $.A. 10:5-31, et seq, (NLA, C. 17:27) If awarded a contract, the Bidder will be required to comply with the requirements of NJ.S.A. 10:531, et seg., and N.A.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 or sanctioned affirmative action program; or 2. A Certificate of Employee Information Report Approval issued in accordance with NJ.A.C, 17:27-4; or 3. An initial Employee Information Report consisting of forms provided by the Affirmative Action Office and completed by Contractor in accordance with NLA.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 NLA.C, 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 NJ.S.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 (Lf yes, submit a copy of such approval.) (No) 2: Do you have a State Certificate of Employee Information Report approval? Yes {IE yes, submit a copy of such approval.) Ro? ‘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 furnish the required documentation pursuant to the law. COMPANY: S7¢4uwG S&CUUT/ES NAME; GARY B6076S sIoNaTuRE: <2—&—P TLE: Co~ otu nwa NOTE:A bid must be tejected as non-responsive if a Bidder fails to comply with requitements of NJ.S.A. 10:5-31, et seq, within stipulated time.

TOWNSHIP OF WEST ORANGE DISCLOSURE OF INVESTMENT ACTIVITIES IN IRAN Proposer: STEMS SECURITIES 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 2 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 | am authorized to submit a proposal: Must check appropriate boxes ls 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 a 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, flnes and/or sanctions will be assessed as provided by law. Part 2: PLEASE PROVIDE FURTHER INFORMATION RELATED TO INVESTMENT ACTIVITIES IN [RAN You must provide a detailed, accurate and precise description of the activities of the proposer, or one of its parents,