AGENT AUTHORIZATION FORM I/We, (Print Bidder name) , Do hereby authorize (print agent’s name), , to act as my/our agent to execute any petitions or other documents necessary to affect the CONTRACT approval PROCESS more specifically described as follows, (IFB NUMBER AND TITLE) , and to appear on my/our behalf before any administrative or legislative body in the county considering this CONTRACT and to act in all respects as our agent in matters pertaining TO THIS CONTRACT. Signature of Bidder Date STATE OF FLORIDA ) ) ss: COUNTY OF ) The foregoing instrument was acknowledged before me by means of ☐physical presence, or ☐online notarization, this day of , 20 , by [NAME OF PERSON], as [TYPE OF AUTHORITY,… e.g. officer, trustee, etc.)] for [NAME OF PARTY ON BEHALF OF WHOM INSTRUMENT WAS EXECUTED]. ☐Personally Known; OR ☐Produced Identification. Type of identification produced: . [CHECK APPLICABLE BOX TO SATISFY IDENTIFICATION REQUIREMENT OF FLA. STAT. §117.05] Notary Public My Commission Expires: (Printed, typed or stamped commissioned name of Notary Public) LEASED EMPLOYEE AFFIDAVIT I affirm that an employee leasing company provides my workers’ compensation coverage. I further understand that my contract with the employee leasing company limits my workers’ compensation coverage to enrolled worksite employees only. My leasing arrangement does not cover un-enrolled worksite employees, independent contractors, uninsured sub-contractors or casual labor exposure. I hereby certify that 100% of my workers are covered as worksite employees with the employee leasing company. I certify that I do not hire any casual or uninsured labor outside the employee leasing arrangement. I agree to notify the County in the event that I have any workers not covered by the employee leasing workers’ compensation policy. In the event that I have any workers not subject to the employee leasing arrangement, I agree to obtain a separate workers’ compensation policy to cover these workers. I further agree to provide the County with a certificate of insurance providing proof of workers’ compensation coverage prior to these workers entering any County jobsite. I further agree to notify the County if my employee leasing arrangement terminates with the employee leasing company and I understand that I am required to furnish proof of replacement workers’ compensation coverage prior to the termination of the employee leasing arrangement. I certify that I have workers’ compensation coverage for all of my workers through the employee leasing arrangement specified below: Name of Employee Leasing Company: Workers’ Compensation Carrier: A.M. Best Rating of Carrier: Inception Date of Leasing Arrangement: I further agree to notify the County in the event that I switch employee-leasing companies. I recognize that I have an obligation to supply an updated workers’ compensation certificate to the County that documents the change of carrier. Name of Contractor: Signature of Owner/Officer: Title: Date: INFORMATION FOR DETERMINING JOINT VENTURE ELIGIBILITY If the bidder is submitting as a joint venture, please be advised that this form MUST be completed and the REQUESTED written joint-venture agreement MUST be attached and submitted with this form. HOWEVER, IF THE BIDDER IS NOT A JOINT VENTURE, CHECK THE FOLLOWING BLOCK: ( ) NOT APPLICABLE
New Work Authorization If the Engineer does not complete the services authorized in a work authorization before the specified completion date and has not requested a supplemental work authorization, the work authorization shall terminate on the completion date. At the sole discretion of the State, it may issue a new work authorization to the Engineer for the incomplete work using the unexpended balance of the preceding work authorization for the project. If approved by the State, the Engineer may calculate any additional cost for the incomplete work using the rates set forth in the preceding work authorization and in accordance with Attachment E, Fee Schedule.
Network Authorization For services that cannot be provided by a network provider, you can request a network authorization to seek services from a non-network provider. With an approved network authorization, the network benefit level will apply to the authorized covered healthcare service. If we approve a network authorization for you to receive services from a non- network provider, our reimbursement will be based on the lesser of our allowance, the non-network provider’s charge, or the benefit limit. For more information, please see the How Non-Network Providers Are Paid section.
Medical Authorization In the event of illness or injury while participating in the above referenced activity, I hereby consent to whatever x-ray, examination, anesthetic, medical, surgical, dental diagnosis or treatment, hospital care and emergency transportation from a licensed physician, surgeon, and/or dentist as deemed necessary for my safety and welfare.
Prior Authorization A determination to authorize a Provider’s request, pursuant to services covered in the MississippiCAN Program, to provide a service or course of treatment of a specific duration and scope to a Member prior to the initiation or continuation of the service.
Licenses and Similar Authorizations The Contractor, at no expense to the City, shall secure and maintain in full force and effect during the term of this Contract all required licenses, permits, and similar legal authorizations, and comply with all related requirements.
SUBMITTAL LABEL In an effort to help promote social distancing measures during the COVID-19 Public Health Emergency, electronic submissions will be accepted by the County. Firms are strongly encouraged to submit responses electronically. Firms will not be permitted to fax or email offers. To maintain a secured sealed process electronic submissions may be made through the Negometrix platform only at: xxxxx://xxx.xxxxxxxxxx.xxx/buyer/691 DO NOT OPEN - SE ALED RESPONSES - DO NOT OPEN RESERVED FOR PUBLIC BID OPENING Company : Contact Name: Contact Phone/ Email: Address: CONTACT: IFB NUMBER: TITLE: XXXXXX XXXXXXX Y 20 - 1058 - MV HEAVY EQUIPMENT PARTS AND LABOR BID DUE DATE: D ELIVER T O : ORANGE COUNTY PROCUREMENT DIVISION INTERNAL OPERATIONS CENTRE II 000 X. XXXXX XXXXXX, 0XX XXXXX XXXXXXX, XX 00000. If submitting via mail or hard copy, use the hard-copy label below and place on front of their outermost sealed envelope/package.
LEGAL AUTHORIZATION (a) The Sub-Recipient certifies that it has the legal authority to receive the funds under this Agreement and that its governing body has authorized the execution and acceptance of this Agreement. The Sub-Recipient also certifies that the undersigned person has the authority to legally execute and bind Sub-Recipient to the terms of this Agreement.
Proposal Work Authorizations The State may issue a proposal work authorization under which the Engineer will submit a proposal for additional work. The proposal must be for additional work that is within the defined scope of work under this contract. The amount to be paid for a proposal work authorization will be a lump sum for each proposal. The lump sum payment will be no less than two percent (2%) and no more than four percent (4%) of the State's estimate of the cost of the additional work. The Engineer may elect without penalty not to submit a proposal in response to a proposal work authorization. Any proposal submitted in response to a proposal work authorization will be the sole property of the State. The State may, at its option, issue similar or identical proposal work authorizations under other contracts, and the proposals submitted in response to the various proposal work authorizations may be compared by the State for the purpose of determining the contract under which the work will be awarded. The determination of the contract under which the work will be awarded will be based on the design characteristics of the proposal and the Engineer's qualifications and will not consider the Engineer's rates.
Credit Card Authorization TO THE EXTENT PERMITTED BY APPLICABLE LAW, YOU IRREVOCABLY AND UNCONDITIONALLY AUTHORIZE XXXXXXX TO CHARGE ALL AMOUNTS DUE UNDER THIS AGREEMENT TO ANY CREDIT CARD YOU PROVIDE TO US, AND YOU AGREE TO INDEMNIFY, DEFEND AND HOLD HARMLESS XXXXXXX WITH RESPECT TO THE SAME.
