Electronic Signatures and Electronic Records. The Parties consent to the use of electronic signatures. The Agreement, and any other documents requiring a signature hereunder, may be signed electronically by the Parties in the manner specified by any applicable City regulation, rule, and/or ordinance. The Parties agree not to deny the legal effect or enforceability of the Agreement solely because it is in electronic form or because an electronic record was used in its formation. The Parties agree not to object to the admissibility of the Agreement in the form of an electronic record, or a paper copy of an electronic document, or a paper copy of a document bearing an electronic signature, on the ground that it is an electronic record or electronic signature or that it is not in its original form or is not an original. This Agreement is expressly subject to and will not become effective or binding on Xxxxxxxx until it is fully approved and executed by Xxxxxxxx. APPROVED AS TO LEGAL FORM: CITY OF THORNTON, COLORADO: Xxxxxxx X. Xxxxxxx III, Interim City Attorney By: , City Attorney Xxxxxxxx Xxxxxxx Finance Director ATTEST: CITY OF THORNTON, COLORADO: Xxxxxxx X. Xxxxxxxxx, City Clerk Xxxx Xxxxxxx, PE Contracts and Purchasing Director ATTEST FOR FIRM SIGNATURE: (If corporation) _<Sample Only> Signature Print Name Title INSERT FIRM NAME: _<Sample Only> Signature Print Name Title EXHIBIT A SERVICE PROVIDER’S SCOPE OF SERVICES Scope of Services to be inserted and completed by the Buyer of Record after an award has been issued by Thornton for the RFP. This is a placeholder for the sample agreement. EXHIBIT B SERVICE PROVIDER’S PERSONNEL AND SUBCONTRACTORS LISTING Personnel and Subcontractors listing to be inserted and completed by the Buyer of Record after an award has been issued by Thornton for the RFP. This is a placeholder for the sample agreement. EXHIBIT C SCHEDULE OF CHARGES Schedule of Charges to be inserted and completed by the Buyer of Record after an award has been issued by Thornton for the RFP. This is a placeholder for the sample agreement. EXHIBIT D HIPAA BUSINESS ASSOCIATE AGREEMENT This Business Associate Agreement (“Agreement”) between the City of Xxxxxxxx (“Covered Entity”) and Company Name (“Business Associate”) is executed to ensure that Business Associate will appropriately safeguard protected health information (“PHI”) that is created, received, maintained, or transmitted on behalf of Covered Entity in compliance with the applicable provisions of Public Law 104-191 of August 21, 1996, known as the Health Insurance Portability and Accountability Act of 1996, Subtitle F – Administrative Simplification, Sections 261, et seq., as amended ("HIPAA"), and with Public Law 111-5 of February 17, 2009, known as the American Recovery and Reinvestment Act of 2009, Title XII, Subtitle D – Privacy, Sections 13400, et seq., the Health Information Technology and Clinical Health Act, as amended (the “HITECH Act”).
Appears in 1 contract
Samples: Sample General Service Agreement
Electronic Signatures and Electronic Records. The Parties consent Each party consents to the use of electronic signaturessignatures by the other party. The This Agreement, and any other documents requiring a signature hereunderunder this Agreement, may be signed electronically by the Parties each party in the manner specified by any applicable City regulation, rule, and/or ordinancethe District. The Parties parties agree not to deny the legal effect or enforceability of the this Agreement solely because it is in electronic form or because an electronic record was used in its formation. The Parties parties agree not to object to the admissibility of the Agreement in the form of an electronic record, or a paper copy of an electronic document, or a paper copy of a document bearing an electronic signature, on the ground that it is an electronic record or electronic signature or that it is not in its original form or is not an original. This The parties are signing this Agreement is expressly subject to and will not become effective or binding on Xxxxxxxx until it is fully approved and executed by Xxxxxxxxthe date stated in the introductory clause. APPROVED AS TO LEGAL FORM: CITY OF THORNTON, COLORADO: Xxxxxxx X. Xxxxxxx III, Interim City Attorney SCHOOL DISTRICT NO. 1 [Vendor Name] By: , City Attorney Xxxxxxxx Xxxxxxx Finance Director ATTESTBy: CITY OF THORNTON, COLORADODPS Signer and Title Signer and title By: Xxxxxxx X. Xxxxxxxxx, City Clerk Xxxx Xxxxxxx, PE Contracts and Purchasing Director ATTEST FOR FIRM SIGNATURE: (If corporation) _<Sample Only> Signature Print Name Title INSERT FIRM NAME: _<Sample Only> Signature Print Name Title EXHIBIT SCHEDULE A SERVICE PROVIDER’S SCOPE OF SERVICES - Scope of Services and Contract Sum SCHEDULE B - Travel Expenses Contractor shall submit all itemized receipts and supporting documentation to receive payment for its Travel Expenses. The District may reject Contractor’s Travel Expenses not supported by itemized receipts and documentation. The District uses the prescribed Federal guidelines for travel and reimbursement. No type of alcohol will be reimbursed and food reimbursements are only for that individual. Lodging reimbursements are only for the room – no room service, phone charges or movies will be reimbursed. Travel reimbursements are only economy seating and baggage fees – no extra leg room, business or first class will be reimbursed. The daily amount for food and lodging is not to exceed the Federal Per Diem rates for the Denver Metropolitan Area. Daily Per Diem: $69.00 x Days Daily Lodging: $178.00 x Days Car Rental: x Days Other Ground Transportation Costs: Actual value of receipts Air Travel Costs: Actual ticket value Total: SCHEDULE C: Code of Conduct and Conflict of Interest Certification I, , certify as an authorized representative of [ ], that I have read the District’s ethical and purchasing policies, as listed below1, related to my company conducting business with the District. I understand that the District’s policies and regulations shall operate as a Code of Conduct. I agree to follow the District’s Code of Conduct, and any legal and regulatory requirements applicable to my company’s performance, work or contract, and that violating the District’s Code of Conduct may result in immediate sanctions up to, and including the termination of my business relationship with the District. I understand that if I have questions concerning the meaning or application of the Code of Conduct or relevant legal and regulatory requirements, I will contact the appropriate District representative. I understand it is my responsibility to disclose any situation that might reasonably appear to be inserted a violation of the Code of Conduct. I understand the absence of a specific guideline, practice or policy covering a particular situation does not relieve me from exercising the highest ethical standards applicable to the circumstances. I have read the Code of Conduct, as listed below, which among other things, restates the District’s policies prohibiting certain activities deemed illegal, unethical or against the best interest of the District. I accept and completed agree to the restrictions stated in the Code of Conduct. I hereby certify that I will comply with the Code of Conduct and to the best of my knowledge, all of my employees, subcontractors, and personnel under my supervision are aware of the Code of Conduct and will comply with its terms. I know and agree that it is incumbent upon me, and my employees to perform satisfactorily and to follow and comply with the District policies and rules as they are issued or modified from time to time. I understand the District’s Code of Conduct is a general guide to acceptable and appropriate behavior, and that I am expected to comply with it even though it may not contain all of the details and information needed during the course of my performance and work with the District. During the period of time of my business relationship with the District, at no time will I, or any employee of mine: (i) engage in human trafficking or procure a commercial sex act; or (ii) use forced labor in the performance of my company’s performance, work or contract with the District, including but not limited to, prison labor, indentured or slave labor, or bonded labor. I understand that if I, or any employee of mine, engage in any such activities my company’s performance, work or contract may be immediately terminated by the Buyer District without penalty Further, when dealing with District employees, I will adhere to the highest ethical standards of Record after an award has been issued by Thornton business conduct. When seeking the resolution of regulatory or ethical issues affecting my company’s interests I will do so solely on the basis of merit and pursuant to proper procedures in dealing with the District and its employees. At no time will I, or any employee of mine offer, provide or solicit, directly or indirectly, any special treatment or favor in return for anything of economic value, or the promise or expectation of future value or gain. In addition, there shall be no entertaining of District employees with the expectation of receiving any future value or gain. I will not accept or offer gifts, employ any person who is working for the RFPDistrict, nor do I have any close,2 or immediate family3 relationships with the District. This If I do, I will immediately disclose the name and relationship of that person or persons and any existing potential conflict of interest with that District employee or any employee who may make decisions in their jobs that would allow him or her to give or receive preferential or favorable consideration in exchange for anything of a personal benefit to themselves or their friends and families. I understand that such situations could interfere with an employee’s ability to make judgments solely in the District’s best interest. Accordingly, I have listed below all relationships and outside activities, which may require disclosure under the policy. I have also listed names, addresses and the nature of the relationships of all persons or entities doing business with the District from whom I, or any member of my immediate family, have received, may receive in the future, directly or indirectly, cash or a gift of more than nominal value ($25.00). Finally, to ensure there is a placeholder for no perceived conflict of interest, I have listed the sample agreement. EXHIBIT B SERVICE PROVIDER’S PERSONNEL AND SUBCONTRACTORS LISTING Personnel and Subcontractors listing to be inserted and completed name of all individuals employed by the Buyer District that are related to me or anyone in my business regardless of Record after an award has been issued his or her position. Printed Name: Title: Signature Date: 1 BC Board Member Conduct Policy; BCB Board Member Conflict of Interest Policy; DJ Purchasing Policy; DJA Purchasing Authority Policy and regulation; DJB Purchasing Procedures Policy; DJE Bidding Practices Policy; DJG Vendor Relations Policy; DJGA Sales Calls and Demonstrations Policy; DK Stewardship of Funds Policy; GBEA Conflict of Interest Policy; and GBEBC Gifts To and Solicitations by Thornton for the RFP. This is Staff Policy.2 Close relationships means all persons, whether family or not, you may have a placeholder for the sample agreement. EXHIBIT C SCHEDULE OF CHARGES Schedule of Charges to be inserted and completed by the Buyer of Record after an award has been issued by Thornton for the RFP. This is a placeholder for the sample agreement. EXHIBIT D HIPAA BUSINESS ASSOCIATE AGREEMENT This Business Associate Agreement (“Agreement”) between the City of Xxxxxxxx (“Covered Entity”) and Company Name (“Business Associate”) is executed to ensure that Business Associate will appropriately safeguard protected health information (“PHI”) that is created, received, maintainedpersonal or business relation with performing work for, or transmitted on behalf of Covered Entity the District. 3 Immediate family means… spouse, partner in compliance with the applicable provisions of Public Law 104-191 of August 21a civil union, 1996children, known as the Health Insurance Portability and Accountability Act of 1996siblings, Subtitle F – Administrative Simplification, Sections 261, et seq., as amended ("HIPAA")parents, and with Public Law 111in-5 laws (mother, father, brother, sister, daughter and son). See, Board Policy GBEA SCHEDULE D - Insurance Requirements General Provisions Contractor agrees to secure, at or before the time of February 17, 2009, known as the American Recovery and Reinvestment Act execution of 2009, Title XII, Subtitle D – Privacy, Sections 13400, et seq.this Agreement, the Health Information Technology following insurance covering all operations, goods or services provided pursuant to this Agreement. Contractor shall provide a copy of this Agreement to its insurance agent or broker. Contractor may not commence services or work relating to the Agreement prior to placement of coverage. Contractor shall keep the required insurance coverage in force at all times during the term of the Agreement, or any extension thereof, during any warranty period, and Clinical Health Act, as amended for three (3) years after termination of the “HITECH Act”)Agreement.
Appears in 1 contract
Samples: Professional Services Agreement
Electronic Signatures and Electronic Records. The Parties consent to the use of electronic signatures. The Agreement, and any other documents requiring a signature hereunder, may be signed electronically by the Parties in the manner specified by any applicable City regulation, rule, and/or ordinance. The Parties agree not to deny the legal effect or enforceability of the Agreement solely because it is in electronic form or because an electronic record was used in its formation. The Parties agree not to object to the admissibility of the Agreement in the form of an electronic record, or a paper copy of an electronic document, or a paper copy of a document bearing an electronic signature, on the ground that it is an electronic record or electronic signature or that it is not in its original form or is not an original. This Agreement is expressly subject to and will not become effective or binding on Xxxxxxxx Thornton until it is fully approved and executed by XxxxxxxxThornton. APPROVED AS TO LEGAL FORM: CITY OF THORNTON, COLORADO: Xxxxxxx X. Xxxxxxx III, Interim City Attorney By: , City Attorney Xxxxxxxx Xxxxxxx Finance Director ATTEST: CITY OF THORNTON, COLORADO: Xxxxxxx X. Xxxxxxxxx, City Clerk Xxxx Xxxxxxx, PE Contracts and Purchasing Director ATTEST FOR FIRM SIGNATURE: (If corporation) ______<Sample Only> >________________ Signature Print Name Title INSERT FIRM NAME: ______<Sample Only> >________________ Signature Print Name Title EXHIBIT A SERVICE PROVIDER’S SCOPE OF SERVICES Scope of Services to be inserted and completed by the Buyer of Record after an award has been issued by Thornton for the RFPIFB. This is a placeholder for the sample agreement. EXHIBIT B SERVICE PROVIDER’S PERSONNEL AND SUBCONTRACTORS LISTING Personnel and Subcontractors listing to be inserted and completed by the Buyer of Record after an award has been issued by Thornton for the RFPIFB. This is a placeholder for the sample agreement. EXHIBIT C SCHEDULE OF CHARGES Schedule of Charges to be inserted and completed by the Buyer of Record after an award has been issued by Thornton for the RFPIFB. This is a placeholder for the sample agreement. EXHIBIT D HIPAA BUSINESS ASSOCIATE AGREEMENT This Business Associate Agreement (“Agreement”) between SOLE PROPRIETORSHIP AFFIDAVIT I, <Sample Only> , swear or affirm under penalty of perjury under the laws of the State of Colorado that: Check Only One ___ I am a United States citizen, OR ___ I am a Permanent Resident of the United States, OR ___ I am lawfully present in the United States pursuant to federal law. I understand that this sworn statement is required by law because I have applied for a public benefit. I understand that state law requires me to provide proof that I am lawfully present in the United States prior to receipt of this public benefit. I further acknowledge that making a false, fictitious, or fraudulent statement or representation in this sworn Affidavit is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado Revised Statute 18-8-503 and it shall constitute a separate criminal offense each time a public benefit is fraudulently received. Signature Date I, _________________________________________, City of Xxxxxxxx employee, observed the identification supplied by the above named individual and affirm that it appears to be valid and is of the following form: CHECK ONLY ONE ___ Colorado Driver’s License or state issued identification card. ___ United States Military or Military Dependent’s Card. ___ Merchant Mariner Card. ___ Native American Tribal Document. ___ Valid Driver’s License or state issued identification card bearing applicant’s photograph issued by one of the following (“Covered Entity”) all states are not listed here; only those that verify lawful presence): Alabama, Arizona, Arkansas, California, Connecticut, Delaware, District of Columbia, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, New Jersey, New York, North Dakota, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina, South Dakota, Virginia, West Virginia, and Company Name (“Business Associate”) is executed to ensure that Business Associate will appropriately safeguard protected health information (“PHI”) that is created, received, maintained, or transmitted on behalf Wyoming. ___ Certificate verifying naturalized status issued by an authorized agency of Covered Entity in compliance the United States bearing Applicant’s intact photograph impressed with the applicable provisions raised embossed seal of Public Law 104-191 the issuing agency. ___ Certificate verifying United States citizenship issued by an authorized agency of August 21the United States bearing Applicant’s intact photograph impressed with the raised embossed seal of the issuing agency. ___ Valid immigration documents demonstrating Lawful Presence and verified through the Systematic Alien Verification for Entitlements, 1996, known administered by the United States Citizenship and Immigration Services of the Department of Homeland Security. Valid Immigration documents are as the Health Insurance Portability and Accountability Act of 1996, Subtitle F – Administrative Simplification, Sections 261, et seqfollows: Unexpired Foreign Passport bearing an unexpired “Processed for I-551” stamp or with an attached unexpired “Temporary I-551” visa. Unexpired Foreign Passport accompanied by an “I-94” indicating a specific future “until” date., as amended ("HIPAA"), and with Public Law 111-5 of February 17, 2009, known as the American Recovery and Reinvestment Act of 2009, Title XII, Subtitle D – Privacy, Sections 13400, et seq., the Health Information Technology and Clinical Health Act, as amended (the “HITECH Act”).
Appears in 1 contract
Samples: Sample General Service Agreement
Electronic Signatures and Electronic Records. The Parties consent Each party consents to the use of electronic signaturessignatures by the other party. The This Agreement, and any other documents requiring a signature hereunderunder this Agreement, may be signed electronically by the Parties each party in the manner specified by any applicable City regulation, rule, and/or ordinancethe District. The Parties parties agree not to deny the legal effect or enforceability of the this Agreement solely because it is in electronic form or because an electronic record was used in its formation. The Parties parties agree not to object to the admissibility of the Agreement in the form of an electronic record, or a paper copy of an electronic document, or a paper copy of a document bearing an electronic signature, on the ground that it is an electronic record or electronic signature or that it is not in its original form or is not an original. This The parties are signing this Agreement is expressly subject to and will not become effective or binding on Xxxxxxxx until it is fully approved and executed by Xxxxxxxxthe date stated in the introductory clause. APPROVED AS TO LEGAL FORM: CITY OF THORNTON, COLORADO: Xxxxxxx X. Xxxxxxx III, Interim City Attorney SCHOOL DISTRICT NO. 1 [Vendor Name] By: , City Attorney Xxxxxxxx Xxxxxxx Finance Director ATTESTBy: CITY OF THORNTON, COLORADODPS Signer and Title Signer and title By: Xxxxxxx X. Xxxxxxxxx, City Clerk Xxxx Xxxxxxx, PE Contracts and Purchasing Director ATTEST FOR FIRM SIGNATURE: (If corporation) _<Sample Only> Signature Print Name Title INSERT FIRM NAME: _<Sample Only> Signature Print Name Title EXHIBIT A SERVICE PROVIDER’S SCOPE OF SERVICES Strategic Sourcing SCHEDULE A- Scope of Services and Contract Sum SCHEDULE B- Travel Expenses Contractor shall submit all itemized receipts and supporting documentation to receive payment for its Travel Expenses. The District may reject Contractor’s Travel Expenses not supported by itemized receipts and documentation. The District uses the prescribed Federal guidelines for travel and reimbursement. No type of alcohol will be inserted reimbursed and completed by the Buyer of Record after an award has been issued by Thornton food reimbursements are only for that individual. Lodging reimbursements are only for the RFProom – no room service, phone charges or movies will be reimbursed. This Travel reimbursements are only economy seating and baggage fees – no extra leg room, business or first class will be reimbursed. The daily amount for food and lodging is a placeholder not to exceed the Federal Per Diem rates for the sample agreement. EXHIBIT B SERVICE PROVIDER’S PERSONNEL AND SUBCONTRACTORS LISTING Personnel and Subcontractors listing to be inserted and completed by the Buyer of Record after an award has been issued by Thornton for the RFP. This is a placeholder for the sample agreement. EXHIBIT C SCHEDULE OF CHARGES Schedule of Charges to be inserted and completed by the Buyer of Record after an award has been issued by Thornton for the RFP. This is a placeholder for the sample agreement. EXHIBIT D HIPAA BUSINESS ASSOCIATE AGREEMENT This Business Associate Agreement (“Agreement”) between the City of Xxxxxxxx (“Covered Entity”) and Company Name (“Business Associate”) is executed to ensure that Business Associate will appropriately safeguard protected health information (“PHI”) that is created, received, maintained, or transmitted on behalf of Covered Entity in compliance with the applicable provisions of Public Law 104-191 of August 21, 1996, known as the Health Insurance Portability and Accountability Act of 1996, Subtitle F – Administrative Simplification, Sections 261, et seqDenver Metropolitan Area., as amended ("HIPAA"), and with Public Law 111-5 of February 17, 2009, known as the American Recovery and Reinvestment Act of 2009, Title XII, Subtitle D – Privacy, Sections 13400, et seq., the Health Information Technology and Clinical Health Act, as amended (the “HITECH Act”).
Appears in 1 contract
Samples: Professional Services Agreement
Electronic Signatures and Electronic Records. The Parties consent to the use of electronic signatures. The Agreement, and any other documents requiring a signature hereunder, may be signed electronically by the Parties in the manner specified by any applicable City regulation, rule, and/or ordinance. The Parties agree not to deny the legal effect or enforceability of the Agreement solely because it is in electronic form or because an electronic record was used in its formation. The Parties agree not to object to the admissibility of the Agreement in the form of an electronic record, or a paper copy of an electronic document, or a paper copy of a document bearing an electronic signature, on the ground that it is an electronic record or electronic signature or that it is not in its original form or is not an original. This Agreement is expressly subject to and will not become effective or binding on Xxxxxxxx Thornton until it is fully approved and executed by XxxxxxxxThornton. APPROVED AS TO LEGAL FORM: CITY OF THORNTON, COLORADO: Xxxxxxx X. Xxxxxxx III, Interim City Attorney By: , City Attorney Xxxxxxxx Xxxxxxx Finance Director ATTEST: CITY OF THORNTON, COLORADO: Xxxxxxx X. Xxxxxxxxx, City Clerk Xxxx Xxxxxxx, PE Contracts and Purchasing Director ATTEST FOR FIRM SIGNATURE: (If corporation) _<Sample Only> Signature Print Name Title INSERT FIRM NAME: _<Sample Only> Signature Print Name Title EXHIBIT A SERVICE PROVIDER’S SCOPE OF SERVICES Scope of Services to be inserted and completed by the Buyer of Record after an award has been issued by Thornton for the RFP. This is a placeholder for the sample agreementSample Agreement. EXHIBIT B SERVICE PROVIDER’S PERSONNEL AND SUBCONTRACTORS LISTING Personnel and Subcontractors listing to be inserted and completed by the Buyer of Record after an award has been issued by Thornton for the RFP. This is a placeholder for the sample agreementSample Agreement. EXHIBIT C SCHEDULE OF CHARGES Schedule of Charges to be inserted and completed by the Buyer of Record after an award has been issued by Thornton for the RFP. This is a placeholder for the sample agreement. EXHIBIT D HIPAA BUSINESS ASSOCIATE AGREEMENT This Business Associate Agreement (“Agreement”) between the City of Xxxxxxxx (“Covered Entity”) and Company Name (“Business Associate”) is executed to ensure that Business Associate will appropriately safeguard protected health information (“PHI”) that is created, received, maintained, or transmitted on behalf of Covered Entity in compliance with the applicable provisions of Public Law 104-191 of August 21, 1996, known as the Health Insurance Portability and Accountability Act of 1996, Subtitle F – Administrative Simplification, Sections 261, et seq., as amended ("HIPAA"), and with Public Law 111-5 of February 17, 2009, known as the American Recovery and Reinvestment Act of 2009, Title XII, Subtitle D – Privacy, Sections 13400, et seq., the Health Information Technology and Clinical Health Act, as amended (the “HITECH Act”).CHARGES
Appears in 1 contract
Samples: Sample General Service Agreement
