Instructions to vendors and general specifications substitute staffing services management program

Part I – Vendor Information

Vendor Name:
Address:
City:				State:	Zip:

The undersigned being authorized to certify, hereby certifies that the submission provided herein represents compliance with the provisions of N.J.S.A.19:44A-20.26and as represented by the Instructions accompanying this form.

_________________________ _______________________ _______________________

Signature Printed Name Title

Part II – Contribution Disclosure

Disclosure requirement: Pursuant to N.J.S.A.19:44A-20.26this disclosure must include all reportable political contributions (more than $300 per election cycle) over the 12 months prior to submission to the committees of the government entities listed on the form provided by the local unit.

• 
  Check here if disclosure is provided in electronic form.
  

Contributor Name	Recipient Name	Date	Dollar Amount
			$

• 
  Check here if the information is continued on subsequent page(s)
  

Continuation Page

C. 271 POLITICAL CONTRIBUTION DISCLOSURE FORM

Required Pursuant To N.J.S.A. 19:44A-20.26

Page ___ of ______
Vendor Name:

Contributor Name	Recipient Name	Date	Dollar Amount
			$

• 
  Check here if the information is continued on subsequent page(s)
  

List of Agencies with Elected Officials Required for Political Contribution Disclosure

N.J.S.A.19:44A-20.26

Local Education Agency: West Long Branch Board of Education
Members of the Board of Education:
Kristin Arvanitis

Meaghan Cavanaugh

Paul Christopher

Mary Gassman

Erin Hegglin

Brian Kramer

Trish McLaughlin

Beth Sarfaty

Sue Trocchia


STOCKHOLDER DISCLOSURE CERTIFICATION
Name of Business:

 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.

OR

 I certify that no one stockholder owns 10% or more of the issued and outstanding stock of the undersigned.

Check the box that represents the type of business organization:

Partnership Corporation Sole Proprietorship

Limited Partnership Limited Liability Corporation Limited Liability Partnership

Subchapter S Corporation

Sign and notarize the form below, and, if necessary, complete the stockholder list below.

Stockholders:

Name:	Name:
Home Address:	Home Address:
Name:	Name:
Home Address:	Home Address:
Name:	Name:
Home Address:	Home Address:

Subscribed and sworn before me this ___ day of ___________, 2 __. (Notary Public) My Commission expires:

_________________________________ (Affiant) ________________________________ (Print name & title of affiant) (Corporate Seal)

AFFIRMATIVE ACTION QUESTIONNAIRE

This form is to be completed and returned with the bid. However, the Board will accept in lieu of this Questionnaire, Affirmative Action Evidence Employee Information Report stapled to this page.

1. Our company has a federal Affirmative Action Plan approval.  Yes No

[If yes, please attach a copy of the plan to this questionnaire.]
2. Our company has a N.J. State Certificate of Employee Information Report.  YesNo

[If yes, please attach a copy of the certificate to this questionnaire.]

3. 
   If you answered “NO” to both questions No. 1 and 2, you must apply for an Affirmative Action Employee Information Report – Form AA302.
   

Please visit the New Jersey Department of Treasury website for the Division of Public Contracts Equal Employment Opportunity Compliance:

www.state.nj.us/treasury/contract_compliance/

1. 
   Click on “Employee Information Report”
   
2. 
   Complete and submit the form with the appropriate payment to:
   

Department of Treasury

Division of Public Contracts/EEO Compliance

P.O. Box 209

Trenton, NJ 08625-0002
All fees for this application are to be paid directly to the State of New Jersey. A copy shall be submitted to the Board of Education within seven (7) days of the notice of the intent to award the contract or the signing of the contract.
I certify that the above information is correct to the best of my knowledge.

Name: ___________________________________________________________________

Signature ________________________________________________________________

Title ___________________________________________ Date _____________________

Name of Company__________________________________________________________

Address __________________________________________________________________

City, State, Zip _____________________________________________________________
DOCUMENTATION CHECKLIST

(Procurement Proposals)

The following documentation is required to be included in the sealed envelope. Failure to provide any of these documents will result in the proposal being called incomplete and eliminate said proposal from further consideration. Valid dates where applicable, will be carefully checked and if found not current, will also result in an incomplete proposal and eliminate the proposal from further consideration. This sheet must be completed and included with all the documents listed below in the envelope.

BID PROPOSAL FORM Yes No
REFERENCE FORM Yes No
PERSONNEL QUALIFICATIONS INFORMATION Yes No
FINANCIAL STABILITY DOCUMENTATION Yes No
AFFIRMATIVE ACTION/RIGHT TO KNOW LANGUAGE Yes No
CORPORATE DISCLOSURE SHEET Yes No
NON-COLLUSION AFFIDAVIT Yes No
C. 271 POLITICAL CONTRIBUTION DISCLOSURE FORM Yes No
STOCKHOLDER DISCLOSURE CERTIFICATION Yes No
AFFIRMATIVE ACTION QUESTIONNAIRE Yes No
CERTIFICATE OF INSURANCE Yes No
NJ BUSINESS REGISTRATION CERTIFICATE Yes No

I have read the above, fully complied with the directions and indicate so by signing in the space below.

SIGNATURE DATE