request for proposal for wireless network equipment upgrade...we are seeking proposals for replacing...

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Page | 1 HOUSTON COUNTY LIBRARY SYSTEM Request for Proposal For Wireless Network Equipment Upgrade Houston County Public Library system Houston County Georgia E-Rate Funding Year 1 July 2021 through 30 June 2022 For all questions about this RFP contact via email: Dixie Henning EMAIL – [email protected] Released On: 1 September 2020 Due On: 22 October 2020 at 5:00 p.m. local time.

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Page 1: Request for Proposal For Wireless Network Equipment Upgrade...We are seeking proposals for replacing the current Wireless Network equipment with enterprise level wireless equipment

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HOUSTON COUNTY LIBRARY SYSTEM

Request for Proposal

For

Wireless Network Equipment Upgrade

Houston County Public Library system

Houston County Georgia

E-Rate Funding Year

1 July 2021 through

30 June 2022 For all questions about this RFP contact via email:

Dixie Henning

EMAIL – [email protected]

Released On:

1 September 2020

Due On:

22 October 2020 at 5:00 p.m. local time.

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OVERVIEW

This project is part of a USAC application for federal “E-RATE” funding. All providers wishing to bid must have a valid SPIN number and be in good standing with USAC. Proposers are expected to assist in the determination of individual component eligibility as outlined in the current USAC Eligible Services List. Proposals will be evaluated with price as highest criteria followed by experience with schools and the E-Rate program. All work described in this Request For Proposal (RFP) is contingent upon funding approval. Houston County Public Library System (HCPLS) reserves the right to terminate any contract, agreement, or work schedule if FCC / USAC "E-RATE" funding is cancelled, altered, or denied. Vendor must use the SPIN method of invoicing [Service Provider Identification Number].

E-Rate discounts are to be taken off all invoices prior to submittal for payment.

Our goal is selecting Wireless Network equipment that can provide the best possible service with sufficient speed for patrons and staff at each of the libraries in the HCPLS. Responders may bid to provide services for all or any of the member libraries in the HCPLS.

The work proposed in these specifications are dependent upon receipt of Erate Funding for Wireless Network Equipment

Upgrade for the Erate Funding Year July 1, 2021 through June 30, 2022

BACKGROUND INFORMATION HCPLS currently has Ruckus ZoneDirector 1200 network controllers, ZoneFlex R500 access points and HP Power-over-Ethernet (PoE) switches at our 3 library locations. Nola Brantley Memorial Library is located at 721 Watson Boulevard, Warner Robins, GA 31093. This library has 1 controller, 1 PoE switch and 7 access points for staff and patrons. Centerville Branch is located at 206 Gunn Road, Centerville, GA 31028. This library has 1 controller, 1 PoE switch and 6 access points for staff and patrons. Perry Branch houses the administrative offices for the HCPLS and is located at 1201 Washington Street, Perry, GA 31069. This library has 1 controller, 1 PoE switch and 6 access points for staff and patrons.

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Cat6 or Cat6+ cabling is installed for existing access points at all 3 locations. Any additional cabling will be run by the contractor. Each branch data room is climate controlled and has a short-term back-up power for emergency power to the equipment. EQUIPMENT AND SERVICES FOR THIS RFP We are seeking proposals for replacing the current Wireless Network equipment with enterprise level wireless equipment with support for current wireless standards including 802.11ac, 802.11n and 802.11ax. In addition to replacing existing equipment, proposals should include all cabling and equipment needed to add one (1) outdoor access point to each library branch. This added outdoor access point is intended to provide wireless access to HCPLS parking areas. The outdoor access point should provide wireless access to our parking areas only and not interfere with neighboring business’ networks to the extent possible. The outdoor access point should include dual-band omni-directional antennas and have the ability to provide both 2.4 GHz and 5 GHz radio rates. The outdoor access point should be weather resistant and be able to withstand the elements. The outdoor access point will be mounted on the exterior of the building and under shelter. Items specified in this RFP are Ubiquiti components. The proposal of Ubiquiti components are encouraged but equivalent products will be accepted as long as specified equipment has the same functionality and there are no yearly license or maintenance fees other than yearly support costs. HCPLS acknowledges that the design differences may vary from vendor to vendor. For this reason, some deviations may be permitted. Your proposal must include all mounting hardware for ceiling and wall mounted wireless access points (WAPs) as well as any rack mounting hardware required. Your Proposal must include all the installation materials, access points, cabling and controller equipment costs. Your proposal should include all installation, setup and configuration of all equipment, including but not limited to VLAN, SSID, Captive Portal and Wireless Use and Statistical Reports for 3 locations. Installation should be turnkey installation. Your proposal should also include training for end-users.

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Listed below are the desired products and quantities for the proposal. These quantities are considered estimates based on testing and evaluations performed by HCPLS and are not absolute. Proposal design differences may adjust quantities if needed. The hardware listed below is in no way intended to be a representation of all material, hardware or other items necessary for a complete proposal or implementation. Any additional materials quoted are done so at the discretion of the vendor. All items listed in submitted proposals are to adhere to the requirements of this RFP. Service providers must use SPIN method of invoicing. Nola Brantley Memorial Library, Warner Robins, GA (1) UniFi® Dream Machine Pro Wireless Controller (7) UniFi® AP AC PRO (1) UniFi® AC Mesh Pro AP (1) UniFi® USW 48 POE Switch Centerville Public Library, Centerville, GA (1) UniFi® Dream Machine Pro Wireless Controller (6) UniFi® AP AC PRO (1) UniFi® AC Mesh Pro AP (1) UniFi® USW 48 POE Switch Perry Public Library, Perry, GA (1) UniFi® Dream Machine Pro Wireless Controller (6) UniFi® AP AC PRO (1) UniFi® AC Mesh Pro AP (1) UniFi® USW 48 POE Switch SCOPE OF WORK Contractor shall provide materials for the install of a complete and functional Wireless Network. All WAPs will need to be mounted securely, connected to the centralized controller, allow clients connections and all SSID are tested prior to signoff. Controller shall connect to and be compatible with any existing firewall. In addition to material and equipment, vendor shall provide labor and any incidental material required for installation. All needed equipment, material and labor costs will need to be included in the project cost and is not to be billed separately following the installation of the project. The work performed under this RFP shall be of good quality and performed in a workmanlike manner. In this context "good quality" means that the work shall meet industry technical standards and quality of appearance.

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FUNCTION AND OPERATION The intended purpose of the Wireless Network is for HCPLS owned wireless equipment and for personal devices of patrons and staff and for the future equipment expansion. Upon completion of the Wireless Network the end users should be unable to notice a difference or experience a problem with connecting to the Wireless Network from the old system. It should appear transparent to them in regards to the current configuration of their device and how it will connect to the Wireless Network, unless it is decided by HCPLS to change portions of the configuration related to initial connectivity. The system should be designed to handle between 200 and 500 devices in a 24 hour period at any branch. This Wireless Network should work seamlessly with our current firewall. The WLAN should be able to provide wireless statistical reports, captive portal functionality, be available only during specific hours and to monitor and drop all unauthorized protocols, i.e. use of BitTorrent, on the WLAN. PRODUCTS Equipment shall be provided and installed in accordance within the manufacturer requirements. General instructions are as follows: A WLAN Controller will be installed and connected to PoE switch located at each library Branch. It will be installed in a standard 19” wide data cabinet. The WAPs are to be wall or ceiling mounted and properly secured to ensure they cannot be easily removed. Each new WAP is to be inventoried with their MAC address and a label is to be placed on each AP that is easily visible. The vendor is to provide the customer a spreadsheet at the completion of the project with all inventories information. The WAPs are to be noted on the building map showing their location and will also be delivered in both paper and electronic format at the completion of the project. Labeling: hand written labels are not acceptable. All labels shall be machine printed unless otherwise instructed by HCPLS staff.

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ACCEPTANCE Acceptance of the Wireless Network Equipment, by Owner, shall be based on the results of testing, functionality, and the receipt of documentation. With regard to functionality, Vendor must demonstrate to Owner that Wireless connections are functional at all buildings of this project and that data signals can be successfully transmitted, bi-directionally. The vendor shall test each new WAP. The Owner reserves the right to have a representative present during all or a portion of the testing process. With regard to documentation, all required documentation shall be submitted to Owner. Any hardware manufacturer support program must be included in your proposal. This RFP is not a contract offer. Acceptance of a proposal neither commits HCPLS to award a contract to any vendor, even if all requirements stated in this RFP are not met, nor limits the library’s rights to negotiate in the library’s best interests. HCPLS reserves the right to contract with a vendor or vendors for reasons other than just price. Failure to answer any questions in this RFP may subject the proposal to disqualification. Failure to meet qualifications and requirements will not necessarily subject a proposal to disqualification. It is important that the vendor understand that this Internet Access Proposal has been submitted on HCPLS’s E-Rate application which, if approved, will entitle us to approximately 50%-80% discount through the Universal Service Fund. If you are not familiar with this process, please call Dixie Henning @ 478-918-6133. INVOICING Vendors submitting responses to this RFP agree to provide discounted billing for services associated with this proposal and seek reimbursement of the discount amount according to the invoicing/reimbursement guidelines of the Schools and Libraries Division of the Universal Service Fund. Service providers must use SPIN method of invoicing. HCPLS will pay for the discounted portion of services provided under this proposal. Invoices should be broken down by individual library listing the appropriate discounted charge for each contracted facility. Total costs may be listed minus the applicable discount amount to arrive at the discounted amount for each library in the HCPLS. Discounts should be applied to each invoice prior to submittal for payment. DEADLINE ENFORCED PROPOSALS DELIVERED AFTER THE TIME AND DATE SET FOR RECEIPT OF PROPOSALS SHALL NOT BE ACCEPTED. IT IS THE POTENTIAL FIRM’S RESPONSIBILITY TO ENSURE TIMELY DELIVERY OF THEIR PROPOSAL. WEATHER, FLIGHT DELAYS, CARRIER ERRORS AND OTHER ACTS OF OTHERWISE EXCUSABLE NEGLECT ARE RISKS ALLOCATED TO FIRMS AND WILL NOT BE

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EXEMPTED FROM DEADLINE REQUIREMENTS. TELEPHONE OR FACSIMILE PROPOSALS WILL NOT BE ACCEPTED. GENERAL CONDITIONS Firms are cautioned that any statements made by HCPLS staff or advisors that materially change any portion of this document are NOT binding on HCPLS, and shall not be relied upon unless subsequently ratified by written amendment. All changes shall be in the form of a written amendment. Oral information obtained otherwise will NOT be considered in awarding a contract. Your proposal or bid is a public document under the Georgia Freedom of Information Act (FOIA), except as to information that may be treated as confidential as an exception to disclosure under the FOIA. If you cannot agree to this standard, please do not submit your proposal or bid. HCPLS accepts no responsibility for any expenses incurred by the Firm in the preparation and presentation of an offer. Such expenses shall be borne exclusively by the firm. HCPLS reserves the right to reject any or all offers; to waive any informality or irregularity not affected by law; to evaluate, in its absolute discretion, the offers submitted; and to award the contract according to the offer which best serves the interest of HCPLS, or to not award the contract if HCPLS determines that it is not in its best interest to do so. All submittals shall become the property of HCPLS, and shall not be returned to the vendor, provided that all proprietary information and/or processes of the vendor contained therein, if any, shall remain the property of the vendor. If the Offeror discovers any ambiguity, conflict, discrepancy, omission or other error in the RFP, Offeror/Proposer shall immediately notify HCPLS of such error in writing and request modification or clarification of the document. The Proposer is responsible for clarifying any ambiguity, conflict, discrepancy; omission or other error in the RFP or it shall be deemed waived. The words “Bidder”, “Firm”, “Supplier”, “Offeror”, “Contractor”, “Proposer”, “Respondent” and “Firm” are used interchangeably throughout this proposal, and are used in place of the person, firm, or corporation submitting a proposal on the scope of services or any part thereof. INSURANCE Contractor is responsible for obtaining necessary insurances, licenses and permits. A. The Firm will maintain or carry Commercial General Liability Insurance coverage in an amount not less than $1,000,000 over the primary insurance.

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B. The Firm will maintain Worker’s Compensation Insurance for all of its employees connected to this agreement. Such insurance shall comply with all applicable state laws and shall be in an amount determined by the Georgia Workers Compensation Statutory Limits. C. The Firm shall provide HCPL a Certificate of Insurance showing proof of insurance. Certificates containing wording that releases the insurance company from liability for non-notification of cancellation of the insurance policy are not acceptable. D. The Firm and/ or its insurers are responsible for payment of any liability arising out of Workers’ Compensation, unemployment, or employee benefits offered to its employees. E. All said insurance shall contain a provision that coverage afforded under the policies will not be cancelled unless and until thirty (30) days prior written notice has been given to HCPL. RIGHT OF REJECTION The HCPLS reserves the right to accept or reject any or all responses to this RFP and to enter into discussion and/or negotiations with one or more qualified vendors at the same time, if such actions are in the best interest of the HCPLS. HCPLS reserves the right to reject any or all proposals or parts thereof, as deemed to be in the best interest of the Library. PROPOSALS FOR SPECIFIC BRANCHES, GROUPS OR SYSTEM WIDE Bidders may submit proposals for individual libraries or for a group of libraries or for all libraries in the HCPLS, as best suits their business and Internet Service Provider capabilities. PROPOSALS FOR SPECIFIC BRANCHES, GROUPS OR SYSTEM WIDE Bidders may submit proposals for individual libraries or for a group of libraries or for all libraries in the HCPLS, as best suits their business and Internet Service Provider capabilities. PROPOSAL DELIVERY Proposals should be submitted in a sealed envelope addressed to the following by mail, delivery service,

or hand delivery, no later than

Thursday 22 October 2020 at 5:00 p.m. local time.

Proposals must be received at the HCPLS Main Office located at 1201 Washington Street, Perry, GA by this date and time. No faxed or emailed copies will be accepted.

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Send Proposals to: HOUSTON COUNTY LIBRARY SYSTEM

Request for Proposal For

Wireless Network Equipment Upgrade 1201 Washington Street

Perry, GA 31069 Any offer submitted as a result of this RFP shall be binding on the firm for forty-five (45) calendar days following the specified opening date. Any offer for which the vendor specifies a shorter acceptance period will be rejected. According to USF Regulations HCPLS MUST select a vendor, award a contract, AND file a form 471 No

Later than 11:59 PM on the day of the close of the FCC Form 471 application filing window (exact date to

be determined by USAC)

NO CONTRACT MAY BE SIGNED PRIOR TO the Allowable Vendor Selection/Contract Date as set by USAC.

Attached to these specifications are two Proposal Forms which must be completely filled out and signed by each bidder and included in their RFP submission QUESTIONS All questions pertaining to this RFP must be submitted in writing by email to [email protected]. All questions must be submitted by Wednesday, October 7, 2020 by 5:00PM and will be answered in the form of an FAQ which will be posted to http://houpl.org/?page_id=2070 no later than Friday, October 16, 2020 by 5:00PM. Bidders are responsible for information, changes, additions, etc., posted on the FAQ on the library website at http://houpl.org/?page_id=2070. These answers shall then be considered a part of the specifications. No questions will be address via telephone. EVALUATION CRITERIA HCPLS will be evaluating and weighing the following criteria when considering the various Internet Access proposals. These standards are listed in descending order of importance.

Evaluation Criteria Weight

Cost effectiveness of service 50%

Comprehensive implementation designed to minimize disruption of current library Internet activities

25%

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Experience and capabilities of account support group 15%

Locality to Houston County Public Libraries 10%

Total 100%

MINIMUM QUALIFICATIONS • Firms must have a minimum of 3 years of experience in providing related services. • Firms must provide at least 2 references. • Firms must have no conflict of interest issues while under contract to HCPLS for these services. • Firms must have a license to do business issued from the State of Georgia. INSTRUCTIONS TO BIDDERS This RFP document and additional pages and/or questions may be viewed, printed, downloaded from the Internet at http://houpl.org/?page_id=2070. The HCPLS reserves the right to reject any or all proposals or any part thereof, to waive any informality in any proposal, to act as sole judge of the merit of each response submitted, to select a firm based on the criteria stated. Any bidder who has demonstrated poor performance during either a current or previous agreement with HCPLS may be considered as an unqualified source and their proposal may be rejected. HCPLS reserves the right to exercise this option as is deemed proper and/or necessary. Vendors should frequently, during the proposal process, check http://houpl.org/?page_id=2070 for updated information. QUALIFICATIONS OF BIDDERS The HCPLS may make such investigation as they deem necessary to determine the ability of bidder to perform the work. HCPLS reserves the right to reject any proposal if investigation of such bidder fails to satisfy the HCPLS that such bidder is properly qualified to carry out the obligations of the contract, and to complete the work contemplated therein. Bidders may be required to submit the names and addresses of the officers or principals of the Corporation, firm or partnership submitting a proposal. Failure to comply could result in the rejection of such proposal as non-responsive. All bidders must be prepared to present suitable evidence of their financial standing.

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HCPLS has the right to reject any and all proposals from any bidder that is in or contemplates bankruptcy of any chapter or nature. Said bidder must notify the HCPLS in writing of any existing condition or knowledge of same. No verbal instructions or information to bidders will be binding. The submission of a proposal will be considered as conclusive evidence of complete examination by a bidder of all instructions, specifications, and addenda. FORM OF CONTRACT The successful bidder will be required to execute a written contract with HCPLS within twenty (20) business days after acceptance of proposal or proposals. It is expressly understood and agreed by the bidders that the contractual obligations of HCPLS to the bidders are effective only 1) after the execution of a contract or contracts signed by all parties and 2) Erate funding is secured from the School and Libraries Division of the Universal Service Fund. Contractors must include Contractor E-Verify Affidavit as part of their submittal package. SPECIFICATIONS These specifications are intended to cover the furnishing of all materials and the performance of all work that may be required or necessary for the complete performance of the contract, and the bidder will be required to do all things that may be necessary to fully complete the work within the purview of these specifications. Equipment and/or material to be furnished shall meet with the approval of the Head of Information Technology Services or designated representative. All equipment and/or material shall conform to the requirements of these specifications, and any equipment and/or material condemned by the Head of Information Technology Services as not meeting these specifications shall at once be removed and replaced with acceptable equipment. ADDENDA AND CLARIFICATIONS HCPLS, at its sole discretion, elect to issue changes to the FRP and will issue changes in the form of a written addendum. Written addenda shall be the ONLY FORM of amendment to the Solicitation. Other written information or verbal communications, including but not limited to discussion in a Pre-Bid conference, shall not constitute a change to the requirements of the RFP. Addenda, if issued, will be posted on to HCPL’s website at http://houpl.org/?page_id=2070 prior to the date and time of the Bid Opening.

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It is the Bidder’s responsibility to ensure receipt of any addenda issued. Failure of any Bidder to receive any such addendum or interpretation shall not relieve the Bidder from any obligations under its Bid as submitted. All addenda shall become part of the Contract documents. HCPLS shall have the right, without invalidating this RFP or any and/or all contracts, to make additions to or deductions from the work covered by these specifications, and in case such deductions or additions are made, an equitable adjustment of the addition to or deduction in cost shall be made between HCPLS and the bidder, as shown in a written amendment to the contract. PROTECTION BY BIDDER All bidders agree to indemnify and hold harmless the HCPLS and their representatives from all suits or actions of every nature and description brought against them or any of them, on account of the use of patented or copyrighted appliances, materials, products or processes, and from all legal expenses and costs of suits regarding the same. Bidders shall obey all Federal, State, County, and City laws or ordinances in any way pertaining to the work, and shall obtain all permits that may be necessary for its performance if required. (a) That in the hiring of employees for the performance of such contract, no bidder, sub-contractor, nor any person acting on behalf of such bidder or sub-contractor shall by reason of race, creed or color discriminate against any citizen of the United States who is qualified and able to perform the work to which the employment relates; (b) Nor shall they in any manner discriminate against or intimidate any employees hired for the performance of the work on account of race, creed or color. House Bill 87, Section 3, E-verify Form. All bidders shall not assign, transfer, convey, sublet or otherwise dispose of the contract or any part thereof to anyone without the written consent of the HCPLS. REQUIREMENT FOR CRIMINAL BACKGROUND CHECKS A. The Contractor shall warrant that they will only assign employees who have passed a criminal

background check to perform work under this contract. The background checks shall

demonstrate the worker has no convictions or pending criminal charges that would render the

worker unsuitable. Disqualifying convictions or charges include, but are not limited to, sexual

offenses, violent offenses, and drug offenses.

B. The Contractor warrants they are supplying employees who have passed a background

check(s). Contractor agrees to defend, indemnify and hold harmless HCPL, its officers, directors

and employees for any claims, suits or proceedings alleging a breach of this warranty.

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EXEMPTION FROM GEORGIA SALES TAXES The HCPLS is exempt from Georgia State Sales Tax. Net prices as shown in the proposal shall exclude said State tax amounts. Bidders shall inform all prospective subcontractors and suppliers from whom they expect to obtain services or supplies of the tax exempt status of the HCPLS. Following a contract award, an exemption certificate will be furnished by HCPLS. E-VERIFY COMPLIANCE The Georgia EVerify law requires contractors and all sub-contractors on Georgia public

contracts (contracts with a government agency) for the physical performance of services over

$2,499.99 in value to enroll in E-Verify, regardless of the number of employees. A contractor or

sub-contractor may be exempt from this requirement if the contractor or sub-contractor has no

employees and does not hire nor intend to hire employees for the purpose of completing any

part of the public contract.

For a public contract, contractors must sign the Contractor E-Verify Affidavit, all subcontractors

must sign the Subcontractor E-Verify Affidavit and all Sub-subcontractors must sign the Sub-

Subcontractor Affidavit. The government agency is required to ensure that the Contractor E-

Verify Affidavit is part of the contract; however, the contractor is responsible for all

subcontractor affidavits and the subcontractors are responsible for the sub-subcontractors

affidavits.

For contractor’s not familiar with Georgia’s E-Verify laws, more information can be found at

https://www.verifyi9.com/state-laws/georgia-e-verify/

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PROPOSAL FORM - STATEMENT OF VENDOR’S QUALIFICATION

To accompany proposals submitted for Internet Access for the Houston County Public Library System. Name of Vendor’s Firm: Name of Company Representative: Business Address: Phone Number: When Organized? Where Organized? Partnership Corporation Vendor must provide a Service Provider Information Number assigned by the Schools and Libraries Division (SLD): SPIN Number: How many years have you been engaged in this business under the present firm name? Please attach to this statement at least three references, including: (name, address, title, phone number and brief description of work performed, including dates of work). Date: Firm Name: By: Title:

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PROPOSAL FORM - SIGNATURE PAGE Date ___________________________ TO: Houston County Public Library System This proposal is submitted in accordance with your RFP inviting proposals to be received for the project identified as “Internet Access.” Having carefully examined the RFP, all instructions, specifications, all addenda and/or FAQs, and being familiar with the various conditions affecting the work, the undersigned, hereby agrees to furnish all material, perform all labor, and do all else necessary to complete the work in strict accordance with the specifications for price as contained herein. In the event this proposal is accepted the undersigned is hereby bound to commence and complete all of the work included under this contract in such time and such manner as designated for the various items the bidder has contracted to supply or perform. In submitting this proposal, it is understood that the unrestricted right is reserved by the Houston County Public Library System in making the award to reject any and all proposals or parts thereof, or to waive any informalities or technicalities in said proposals. The undersigned hereby certifies that this proposal is genuine and made in the interest or in behalf of any person, firm or corporation not herein named; that the undersigned has not directly or indirectly induced or solicited any bidder to refrain from submitting proposals, and that the undersigned has not, in any manner, sought by collusion to secure for himself an advantage over any other bidder. TOTAL AMOUNT PROPOSAL OPTION: Bidder MUST provide Federal EIN or SSN: and ERate SPIN: (Print Name) Proposal must be signed for Consideration: (Signature) (Date)

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Contractor Affidavit under O.C.G.A. § 13-10-91(b)(1)

By executing this affidavit, the undersigned contractor verifies its compliance with O.C.G.A. § 13-10-91, stating affirmatively that the individual, firm or corporation which is engaged in the physical performance of services on behalf of ____________ _____________________________ (name of employer) has registered with, is authorized to use and uses the federal work authorization program commonly known as E-Verify, or any subsequent replacement program, in accordance with the applicable provisions and deadlines established in O.C.G.A. § 13-10-91. Furthermore, the undersigned contractor will continue to use the federal work authorization program throughout the contract period and the undersigned contractor will contract for the physical performance of services in satisfaction of such contract only with subcontractors who present an affidavit to the contractor with the information required by O.C.G.A. § 13-10-9 I (b). Contractor hereby attests that its federal work authorization user identification number and date of authorization are as follows: _____________________________ _______________ Federal Work Authorization User Identification Number _____________________________ Date of Authorization ____________________________________________ Name of Contractor ____________________________________________ Name of Project ____________________________________________ Name of Public Employer I hereby declare under penalty of perjury that the foregoing is true and correct. ____________________________________________ Executed on _______, 20____, in________________ (city), _______ (state) ____________________________________________ Signature of Authorized Officer or Agent ____________________________________________ Printed Name and Title of Authorized Officer or Agent SUBSCRIBED AND SWORN BEFORE ME ON THIS THE ____ DAY OF __________, 20____ ___________________________________________ NOTARY PUBLIC My Commission Expires: ____________________