Common use of AGENT AUTHORIZATION FORM Clause in Contracts

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

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 : I certify that the foregoing instrument was acknowledged before me by means of ☐physical presence, or ☐online notarization, this day of , 20 by . He/she is personally known to me or has produced as identification and did/did not take an oath. Witness my hand and official seal in the county and state stated above on the day of , by [NAME OF PERSON], as [TYPE OF AUTHORITY,… e.g. officer, trustee, etc.)] for [NAME OF PARTY ON BEHALF OF WHOM INSTRUMENT WAS EXECUTED]in the year . ☐Personally Known; OR ☐Produced Identification. Type Signature of identification produced: . [CHECK APPLICABLE BOX TO SATISFY IDENTIFICATION REQUIREMENT OF FLA. STAT. §117.05] Notary Public (Notary Seal) Notary Public for the State of 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

AGENT AUTHORIZATION FORM. I/We, (Print Bidder Quoter 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 RFQ 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 Quoter 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 quoter 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 QUOTER IS NOT A JOINT VENTURE, CHECK THE FOLLOWING BLOCK: ( ) NOT APPLICABLE

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

AGENT AUTHORIZATION FORM. I/We, (Print Bidder Proposer 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 RFP 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 Proposer Date STATE OF FLORIDA ) ) ss: COUNTY OF ) The : I certify that the foregoing instrument was acknowledged before me by means of ☐physical presence, or ☐online notarization, this day of , 20 by . He/she is personally known to me or has produced as identification and did/did not take an oath. Witness my hand and official seal in the county and state stated above on the day of , by [NAME OF PERSON], as [TYPE OF AUTHORITY,… e.g. officer, trustee, etc.)] for [NAME OF PARTY ON BEHALF OF WHOM INSTRUMENT WAS EXECUTED]in the year . ☐Personally Known; OR ☐Produced Identification. Type Signature of identification produced: . [CHECK APPLICABLE BOX TO SATISFY IDENTIFICATION REQUIREMENT OF FLA. STAT. §117.05] Notary Public (Notary Seal) Notary Public for the State of 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:

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 : I certify that the foregoing instrument was acknowledged before me by means of ☐physical presence, or ☐online notarization, this day of , 20 by . He/she is personally known to me or has produced as identification and did/did not take an oath. Witness my hand and official seal in the county and state stated above on the day of , by [NAME OF PERSON], as [TYPE OF AUTHORITY,… e.g. officer, trustee, etc.)] for [NAME OF PARTY ON BEHALF OF WHOM INSTRUMENT WAS EXECUTED]in the year . ☐Personally Known; OR ☐Produced Identification. Type Signature of identification produced: . [CHECK APPLICABLE BOX TO SATISFY IDENTIFICATION REQUIREMENT OF FLA. STAT. §117.05] Notary Public (Notary Seal) Notary Public for the State of 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 CERTIFICATION REGARDING LOBBYING FOR DETERMINING JOINT VENTURE ELIGIBILITY If the bidder is submitting as a joint ventureCONTRACTS, please GRANTS, LOANS, AND COOPERATIVE AGREEMENTS APPENDIX A, 44 C.F.R. PART 18 (To be advised that this form MUST be completed and the REQUESTED written joint-venture agreement MUST be attached and submitted with this form. HOWEVEReach bid or offer exceeding $100,000) The following certification and disclosure regarding payments to influence certain federal transactions are made per the provisions contained in 31 U.S.C 1352, IF THE BIDDER IS NOT A JOINT VENTUREthe “Xxxx Anti-Lobbying Amendment.” The undersigned [Contractor] certifies, CHECK THE FOLLOWING BLOCK: ( ) NOT APPLICABLEto the best of his or her knowledge, that:

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 : I certify that the foregoing instrument was acknowledged before me by means of ☐physical presence, or ☐online notarization, this day of , 20 by . He/she is personally known to me or has produced as identification and did/did not take an oath. Witness my hand and official seal in the county and state stated above on the day of , by [NAME OF PERSON], as [TYPE OF AUTHORITY,… e.g. officer, trustee, etc.)] for [NAME OF PARTY ON BEHALF OF WHOM INSTRUMENT WAS EXECUTED]in the year . ☐Personally Known; OR ☐Produced Identification. Type Signature of identification produced: . [CHECK APPLICABLE BOX TO SATISFY IDENTIFICATION REQUIREMENT OF FLA. STAT. §117.05] Notary Public (Notary Seal) Notary Public for the State of My Commission Expires: (Printed, typed or stamped commissioned name of Notary Public) EXHIBIT A 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:

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 : I certify that the foregoing instrument was acknowledged before me by means of ☐physical presence, or ☐online notarization, this day of , 20 by . He/she is personally known to me or has produced as identification and did/did not take an oath. Witness my hand and official seal in the county and state stated above on the day of , by [NAME OF PERSON], as [TYPE OF AUTHORITY,… e.g. officer, trustee, etc.)] for [NAME OF PARTY ON BEHALF OF WHOM INSTRUMENT WAS EXECUTED]in the year . ☐Personally Known; OR ☐Produced Identification. Type Signature of identification produced: . [CHECK APPLICABLE BOX TO SATISFY IDENTIFICATION REQUIREMENT OF FLA. STAT. §117.05] Notary Public (Notary Seal) Notary Public for the State of 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: Name of Contractor: Signature of Owner/Officer: Title: Date: 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.

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 : I certify that the foregoing instrument was acknowledged before me by means of ☐physical presence, or ☐online notarization, this day of , 20 by . He/she is personally known to me or has produced as identification and did/did not take an oath. Witness my hand and official seal in the county and state stated above on the day of , by [NAME OF PERSON], as [TYPE OF AUTHORITY,… e.g. officer, trustee, etc.)] for [NAME OF PARTY ON BEHALF OF WHOM INSTRUMENT WAS EXECUTED]in the year . ☐Personally Known; OR ☐Produced Identification. Type Signature of identification produced: . [CHECK APPLICABLE BOX TO SATISFY IDENTIFICATION REQUIREMENT OF FLA. STAT. §117.05] Notary Public (Notary Seal) Notary Public for the State of 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:

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 : I certify that the foregoing instrument was acknowledged before me by means of ☐physical presence, or ☐online notarization, this day of , 20 by . He/she is personally known to me or has produced as identification and did/did not take an oath. Witness my hand and official seal in the county and state stated above on the day of , by [NAME OF PERSON], as [TYPE OF AUTHORITY,… e.g. officer, trustee, etc.)] for [NAME OF PARTY ON BEHALF OF WHOM INSTRUMENT WAS EXECUTED]in the year . ☐Personally Known; OR ☐Produced Identification. Type Signature of identification produced: . [CHECK APPLICABLE BOX TO SATISFY IDENTIFICATION REQUIREMENT OF FLA. STAT. §117.05] Notary Public (Notary Seal) Notary Public for the State of My Commission Expires: (Printed, typed or stamped commissioned name of Notary Public) EXHIBIT A 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: Name of Contractor: Signature of Owner/Officer: Title: Date: 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.

AGENT AUTHORIZATION FORM. I/We, (Print Bidder Quoter 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 TITLEY21-157-ZR Hearing Officer) , 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 Quoter 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 quoter 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 QUOTER IS NOT A JOINT VENTURE, CHECK THE FOLLOWING BLOCK: ( ) NOT APPLICABLE

AGENT AUTHORIZATION FORM. I/We, (Print Bidder Quoter 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 RFQ 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 Quoter 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: We do not lease employees. 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: Hill York Service Company, LLC Signature of Owner/Officer: Title: Vice President of Sales Date: INFORMATION FOR DETERMINING JOINT VENTURE ELIGIBILITY If the bidder is submitting as a joint venture5/3/2023 Xxx XxXxxxxx, please be advised that Governor Xxxxxxx X. Xxxxxxx, Secretary STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD THE MECHANICAL CONTRACTOR HEREIN IS CERTIFIED UNDER THE PROVISIONS OF CHAPTER 489, FLORIDA STATUTES XXXXXX, XXXXX X XXXX YORK SERVICE COMPANY, LLC 0000 X XXXXXXX XXX FORT LAUDERDALE FL 33316 LICENSE NUMBER: CMC1250709 EXPIRATION DATE: AUGUST 31, 2024 Always verify licenses online at XxXxxxxxxXxxxxxx.xxx Do not alter this form MUST be completed and the REQUESTED written joint-venture agreement MUST be attached and submitted with this document in any form. HOWEVER, IF THE BIDDER IS NOT A JOINT VENTURE, CHECK THE FOLLOWING BLOCK: ( ) NOT APPLICABLE.

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 : I certify that the foregoing instrument was acknowledged before me by means of ☐physical presence, or ☐online notarization, this day of , 20 by . He/she is personally known to me or has produced as identification and did/did not take an oath. Witness my hand and official seal in the county and state stated above on the day of , by [NAME OF PERSON], as [TYPE OF AUTHORITY,… e.g. officer, trustee, etc.)] for [NAME OF PARTY ON BEHALF OF WHOM INSTRUMENT WAS EXECUTED]in the year . ☐Personally Known; OR ☐Produced Identification. Type Signature of identification produced: . [CHECK APPLICABLE BOX TO SATISFY IDENTIFICATION REQUIREMENT OF FLA. STAT. §117.05] Notary Public (Notary Seal) Notary Public for the State of 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: Name of Contractor: Signature of Owner/Officer: Title: Date: 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 CERTIFICATION REGARDING LOBBYING FOR DETERMINING JOINT VENTURE ELIGIBILITY If the bidder is submitting as a joint ventureCONTRACTS, please GRANTS, LOANS, AND COOPERATIVE AGREEMENTS APPENDIX A, 44 C.F.R. PART 18 (To be advised that this form MUST be completed and the REQUESTED written joint-venture agreement MUST be attached and submitted with this form. HOWEVEReach bid or offer exceeding $100,000) The undersigned [Contractor] certifies, IF THE BIDDER IS NOT A JOINT VENTUREto the best of his or her knowledge, CHECK THE FOLLOWING BLOCK: ( ) NOT APPLICABLEthat:

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: