Fillable HOUSING REHABILITATION PROGRAM APPLICATION FOR CONTRACTOR CERTIFICATION (Desoto County, Florida)

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HOUSING REHABILITATION PROGRAM APPLICATION FOR CONTRACTOR CERTIFICATION (Desoto County, Florida)

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The HOUSING REHABILITATION PROGRAM APPLICATION FOR CONTRACTOR CERTIFICATION (Desoto County, Florida) form is 7 pages long and contains:

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  • 12 check-boxes
  • 93 other fields

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HOUSING REHABILITATION PROGRAM
APPLICATION FOR CONTRACTOR CERTIFICATION
Name:
Company Name:
Business Address:
Telephone Number(s):
Fax Number:
Email Address:
Residence Address:
License Number:
Social Security or
Federal I.D. Number:
Business is a:
Sole Proprietorship
Corporation in the State of
Partnership
Owner(s) and addresses:
Officers (Name and Title) and addresses:
Name of Insuring Company:
Address:
Policy Number:
Page Two
Comprehensive Public Liability Coverage: $
Property Damage Coverage: $
Workmen's Compensation Coverage:$
Number of years in business under present name:
Previous business?
Yes
No
If yes: Name
From:
To:
Where:
Name
From:
To:
Where:
Local creditors (banks, savings & loans, other):
Name
Address
Name
Address
Name
Address
Suppliers used frequently and currently:
Name
Address
Name
Address
Name
Address
Page Three
Subcontractors:
Electric:
Plumbing:
Mechanical:
Other
Recent Customers:
Name:
Address:
Phone number:
Name:
Address:
Phone number:
Name:
Address:
Phone number:
Name:
Address:
Phone number:
CONTINUE TO NEXT PAGE
Page Four
Current Employees:
Name:
Address:
Phone number:
Name:
Address:
Phone number:
Name:
Address:
Phone number:
Name:
Address:
Phone numbers:
Name:
Address:
Phone number:
Name:
Address:
Phone number:
Name:
Address:
Phone numbers:
Name:
Address:
Phone number:
Page Five
Superintendent for job is usually (check one):
Contractor
Employee
Have you (personally or under present or past businee) been declared bankrupt during the past (5) years?
Yes
No
If yes, have debts been paid?
The undersigned Contractor certifies that all information given herein is correct and further agrees:
1. That his contractor licenses(s) is (are) current, and that he will maintain in a current status all license(s)
as required by the County and State.
2. The insurance and workmen's compensation will be maintained as required by the Housing Department.
3. To allow the Housing Department to check and reference named herein or elsewhere in determining his
competence and integrity as a contractor.
4. That the work will be performed in accordance with all code standards, zoning regulations and
specifications, subject to a clear final inspection by the Housing Rehabilitation Program, Building
Inspection Department, and Property Owner.
5. That if the work is found to be unsatisfactory by thte Housing Department, or the Building Inspector, or
if contract relations between the Contractor and the Homeowner or other parties are found to be
unsatisfactory, the Contractor's name may be removed from the approved list, with such accompanying
publicity as deemed necessary.
6. That he will abide by regulations pertaining to Equal Employment Opportunity.
7. That he has a satisfactory record regarding complaints filed against the contractor at the state, federal or
local level and is not on any list of debarred contractors issued by the Federal or State DOL, HUD or DCA.
Date:
Signed:
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signature
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ATTACHMENT A
SWORN STATEMENT UNDER
SECTION 287.133(3)(A), Florida Statutes,
ON PUBLIC ENTITY CRIMES
THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER
OFFICIAL AUTHORIZED TO ADMINISTER OATHS:
1. This sworn statement is submitted to DeSoto County by
for
and its Federal Employer identification No. (FEIN) is
2. I understand that a "public entity crime" as defined in Paragraph 287.133(1)(g), Florida Statutes, means a
violation of any state of federal law by a person with respect to and directly related to the transaction of business
with any public entity or with an agency or political subdivision of any other state or of the United States, including,
but not limited to, any bid or contract for goods or services to be provided to any public entity or an agency or
political subdivision of any other state or of the United States and involving antitrust, fraud, theft, bribery,
collusion, racketeering, conspiracy, or material misrepresentation.
3. I understand that "convicted" of "conviction" as defined in Paragraph 287.133(1)(b), Florida Statues, means a find
of guilt or a conviction of a public entity crime, with or without an adjudication of guilt, in any federal or state jury
verdict, non jury trial, entry of a plea of guilty or nolo contendere.
4. I understand that an "affiliate" as defined in Paragraph 287.133(1)(a), Florida Statutes,
means:
1. A predecessor or successor of a person convicted of a public entity crime; or
2. An entity under the control of any natural person who is active in the
management of the entity and who has been convicted of a public entity crime.
The term "affiliate" includes those officers, directors, executives, partners,
shareholders, employees, members, and agents who are active in the
management affiliate. The ownership by one person of shares constituting a
controlling interest in another person, or a pooling of equipment or income
among persons when not for fair market value under an arm's length
agreement, shall be a prima facie case that one person controls another person.
A person who knowingly enters into a joint venture with a person who has
been convicted of a public entity crime in Florida during the preceding 36
months shall be considered an affiliate.
5. I understand that a "person" as defined in Paragraph 287.133(1)(e),Florida Statutes, means any natural person or
entity organized under the laws of any state or of the United States with the legal power to enter into a binding
contract and which bids or applies to bid on contracts for the provisions of goods or services let by a public entity,
or which otherwise transacts or applies to transact business with a public entity. The term "person" includes those
offices, directors, executives, partners, shareholders, employees, members, and agents who are active in
management of an entity.
Based on information and belief the statement, which I have marked below is true in relation to the entity submitting this sworn
statement. (Please indicate which statement applies.)
_______ N
either the entity submitting this sworn statement, nor any officers, directors, executives,
partners, shareholders, employees, members, or agents who are active in management of the
entity, nor any affiliate of the entity has been charged with and convicted of a public entity
crime subsequent to July 1, 1989.
_______ T
he entity submitting this sworn statement, or one or more of its officers, directors,
executives, partners, shareholders, employees, members, or agents who are active in
management of the entity, or an affiliate of the entity has been charged with and convicted
of a public entity crime subsequent to July 1, 1989.
________ T
he entity submitting this sworn statement, or one or more of its officers, directors,
executives, partners, shareholders, employees, members, or agents who are active in the
management of the entity, or an affiliate of the entity has been charged with and convicted
of a public entity crime subsequent to July 1, 1989. However, there has been a subsequent
proceeding before a Hearing Officer of the State of Florid, Division of Administrative
Hearing and the Final Order entered by the Hearing Officer determined that it was not in the
public interest to place the entity submitting this sworn statement on the convicted vendor
list. (Attach copy of the final order.)
I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR THE
PUBLIC ENTITY IDENTIFIED IN PARAGRAPH ONE (1) ABOVE IS FOR THAT PUBLIC ENTITY ONLY
AND, THAT THIS FORM IS VALID THROUGH DECEMBER OF THE CALENDAR YEAR IN WHICH IT IS
FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO
ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION
287.017 FLORIDA STATUES, FOR CATEGORY TOW OF ANY CHANGE IN THE INFORMATION
CONTAINED IN THIS FORM.
_________
_________________________________
Signature
S
worn to and subscribed before me this _______day of ______________, 20 _____.
P
ersonally known_______________
_________
_____________________
Or produced identification
_____________________________
Notary Public – State of Florida
_________
_____________________
(Type of identification) My commission expires________________
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HOUSING REHABILITATION PROGRAM APPLICATION FOR CONTRACTOR CERTIFICATION (Desoto County, Florida)

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Completed 12 August 2021

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