CHABOT-LAS POSITAS COMMUNITY COLLEGE DISTRICT. INVITATION FOR BID No

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1 CHABOT-LAS POSITAS COMMUNITY COLLEGE DISTRICT INVITATION FOR BID No Dental Chairs, Operator Stools, and Accessories - Chabot College Bids Due: May 22, 2007at 2:00 P.M. Purchasing & Warehouse Services Department District Office 5020 Franklin Drive Pleasanton, California 94588

2 INVITATION FOR BID NO Dental Chairs, Operator Stools, and Accessories - Chabot College SECTION A BACKGROUND AND PURPOSE Chabot-Las Positas Community College District (District), (CLPCCD), is seeking to purchase new and unused Dental Chairs, Operator Stools, and Accessories for instructors and students at Chabot College. The purpose of this Invitation for Bid (IFB) is to establish a contract with a vendor or vendors to furnish, deliver, install, successfully operate and provide adequate training on the proper use and maintenance of, the new Dental Chairs, Operator Stools, and Accessories. In this document, CLPCCD is requesting sealed bids and competitive pricing from qualified firms. Bidders are encouraged to investigate and provide all possible educational, quantity and other discounts. SECTION B NOTICE TO BIDDERS Notice is hereby given that the Board of Trustees of the Chabot-Las Positas Community College District, State of California, hereby calls for sealed bids for BID No , Dental Chairs, Operator Stools, and Accessories, Chabot College to be delivered to the Buyer, Purchasing and Warehouse Services Department, 5020 Franklin Drive, Pleasanton, California until May 22, 2007 at 2:00 p.m. at which time and place the bids will be opened and publicly read. Faxed or ed bids will not be accepted. Bids shall be presented in accordance with the specifications for the same, which are included here and are on file with the Buyer, Purchasing and Warehouse Services Department at the office address listed above. Inquiries regarding this bid should be directed to the Buyer, Purchasing and Warehouse Services Department in writing, via facsimile or at fax (925) or echiu@clpccd.org. Reference Bid No on all inquiries. The Board of Trustees reserves the right to reject any and all bids or any and all items of such bids. This bid is subject to any and all applicable laws, regulations and standards. SECTION C EQUIPMENT LIST AND SPECIFICATIONS CLPCCD requests prices for each of the items described in the Bid Form. Page 1 of 15

3 SECTION D - BID FORM AND SIGNATURE FORM BID FORM Bidder Name: ITEM No. QTY. UNIT DESCRIPTION 1 18 EA ADEC 511 Dental Chair w/ Upholstery, Taupe color. No Substitute SUPPLIED STANDARD YES OR NO? Unit Price Extended Price 2 18 EA ADEC 571 Unit Mount Light No Substitute 3 18 EA 4 14 EA 5 14 EA ADEC Cascade 1601 Doctor's Stool No Substitute ADEC Misc Parts to complete installation using the existing 3130 Delivery Systems No Substitute Labor to Install Fourteen (14) EA. of the above items 1-4 (non taxable) Applicable Sales Tax (8.75%) 6 Sub-Total Less Trade-In Discount for Fourteen (14) A-dec model 1015 Chairs s/n # with light # 6300 s/n # k Grand Total Unless otherwise instructed, bid manufacturers and models listed. The District reserves the right to, partially or wholly, accept or reject any and all bids. ANY OFFER ACCEPTED BY THE DISTRICT MUST COMPLY WITH DELIVERY SCHEDULE REQUIRED BY SECTION F. BIDDER CERTIFIES COMPLIANCE WITH DELIVERY SCHEDULE: YES NO WARRANTY INCLUDED: YES NO. Reference SECTION E. Page 2 of 15

4 SIGNATURE FORM TO: CHABOT-LAS POSITAS COMMUNITY COLLEGE DISTRICT, a California Community College District, acting by and through its Board of Trustees (the "District"), 5020 Franklin Drive, Pleasanton, California FROM: (Firm Name of Bidder) (Address) (City, State, Zip Code) (Telephone and Facsimile) (Name(s) of Bidder's Authorized Representative(s)) 1. Bid. 1.1 Bid Amounts. The undersigned Bidder proposes and agrees to provide the equipment, materials, services and related documentation required for the bid described as, Bid No , Dental Chair, Operator Stools, and Accessories, Chabot College, in the amounts listed on the Bid Forms. The bid amounts are exclusive of any State of California or local sales or use. The Bidder confirms that it has checked all of the above figures and understands that neither the District nor any of its agents, employees or representatives shall be responsible for any errors or omissions on the part of the undersigned Bidder in preparing and submitting this Bid. 1.2 Acknowledgment of Bid Addenda. In submitting this Bid, the undersigned Bidder acknowledges receipt of all Bid Addenda issued by or on behalf of the District, as set forth below. The Bidder confirms that this Bid incorporates and is inclusive of, all items or other matters contained in Bid Addenda. Addenda Nos. received, acknowledged and incorporated into this Bid. (initial) 2. Documents Accompanying Bid. The Bidder has submitted with this Bid the following: (a) Non-Collusion Affidavit; (b) Bid Forms; (c) Bid Signature Form; (d) and Drug-Free Workplace Certification (e) warranty information and (f) references. The Bidder acknowledges that if this Bid and the foregoing documents are not fully in compliance with applicable requirements set forth in the Notice Calling for Bids, the Instructions for Bidders and in each of the foregoing documents, the Bid may be rejected as non-responsive. Page 3 of 15

5 3. Award of Contract. It is the intent of the District to issue a Purchase Order(s). It is expected that the successful contractor(s) will meet all requirements of this bid and the purchase order. 4. Acknowledgement and Confirmation. The undersigned Bidder acknowledges its receipt, review and understanding of the business requirements, specifications and other contract documents pertaining to this bid. The undersigned Bidder certifies that the contract documents are, in its opinion, adequate, feasible and complete. The undersigned bidder certifies that is has, all necessary equipment, personnel, materials, technical and financial ability to complete the Work for the amount bid herein within the Contract time and in accordance with the Contract Documents. By: (Authorized Signature) (Typed or Printed Name) (END OF SIGNATURE FORM) Page 4 of 15

6 SECTION E - WARRANTY REQUIREMENTS Warranties are required. Provide all applicable warranty information offered hereunder. Warranty information may be attached to this bid as necessary. SECTION F DELIVERY, INSTALLATION AND SPECIAL STORAGE REQUIREMENTS Time is of the essence. The District must ensure the continuation of the educational program. The District therefore requires that the equipment listed herein be installed, tested and ready for use by students during the period July 11, 2007 through July 13, 2007, unless otherwise agreed to by the District representative. Any bidder submitting a response to this invitation thereby guarantees compliance with the delivery, installation and training requirements. Partial Delivery and Storage by Vendor: Vendor is required to complete 14 stations at Chabot College in their entirety. Four (4) stations will not be completed until a future construction project remodels the facility and expands the Clinic to 18 total stations. Therefore the successful vendor will be required to furnish and store four (4) complete stations as specified in items 1-3 of the Bid Form at no additional charge. Upon successful completion of the 14 current stations the District, based upon proof that the remaining equipment of four (4) stations is properly stored and covered for risk of damage or theft by insurance, will make payment to Vendor for the additional quantity of the specified items. At such time as the construction work has advanced and the facility made ready to accept the District owned and stored equipment for the four (4) new stations, the successful vendor will be required to deliver the equipment. Other Vendor Responsibility: 1. All deliveries will be made to the Chabot College Dental Hygiene Clinic Building 2200, Room Equipment shall be successfully off loaded from the truck, and set in place, set up and successfully operated on the ground, in place by vendor. The vendor will connect the new dental chairs to the District s existing utility boxes and waterlines. The utility box connection is 1 ¾. 2. TRADE IN and REMOVAL of 14 old dental chairs with accessories (ADEC Model 1015) and 14 operator stools by the successful bidder shall take place on Monday July 9, 2007 starting at 8:00AM. The Dental Clinic does not have a loading dock and is not immediately adjacent to a parking lot. Therefore, the successful bidder must plan accordingly to move equipment to and from the Dental Clinic. 3 All bidder prices must be inclusive of trade-in credit for existing equipment; training; costs to remove and haul away existing equipment; delivery, off-loading, assembly, and installation of new equipment; and the removal off site, of all related packing materials and debris. Page 5 of 15

7 District Responsibility: CLPCCD staff from the District s Maintenance and Operations Department will disconnect the existing umbilical from the utility boxes on or before July 9, 2007 and prior to receipt of the new chairs. The District s custodial staff will clean the Dental Clinic floors on July 10, The Campus location is as follows: Chabot College Hesperian Blvd. Hayward, California Please view the web site for general campus information: Orders require an Authorized District Purchase Order and will be placed via , fax, phone or U.S. Mail from CLPCCD's Purchasing Department. All shipments shall be made FOB: destination, Freight: prepaid and allowed. SECTION G - CONTRACT TIME The successful firm will be required to complete the contract by the completion date provided in the Bid Form unless otherwise mutually agreed upon by both parties. After receipt of order, vendors(s) shall furnish, deliver and install the equipment in accordance with the delivery requirements as directed by the Dental Hygiene Program Director or Dean of Health, PE & Athletics. It is required that contractor provide expedited delivery whenever the delivery and installation needs of CLPCCD dictate that need. SECTION H - INSTRUCTIONS TO BIDDERS An original and one (1) copy of the bid must be submitted. Bids must be addressed and delivered no later than 2:00 PM. PST, May 22, Please plan deliveries accordingly. Deliver bids to: Eva Chiu, Buyer Purchasing and Warehouse Services Department Chabot-Las Positas Community College District, District Office 5020 Franklin Drive Pleasanton, California GENERAL INSTRUCTIONS: 1. Bids received after the deadline for closing will be returned unopened unless necessary for identification purposes. CLPCCD is not responsible for mail/messenger delays. 2. The District reserves the right to conduct discussions with all bidders, including the Page 6 of 15

8 bidder(s) who appear(s) to have been selected, to request or require clarification, additional information or additional documentation prior to an official award(s). An oral presentation prior to awards(s) may be required by the District. 3. Any information considered to be proprietary by the bidder shall be marked or stamped "Proprietary Information." Pricing information will not be considered proprietary. 4. Award: The award shall be made to the responsible bidder(s) providing the lowest responsive bid. The award will be in accordance with CLPCCD Board Policy and Procedures, all laws, rules and regulations. CLCCD reserves the right to award one or more purchase orders. 5. Format: Bids must be submitted on the CLPCCD Bid Forms and Bid Signature Form along with any other required submittals that meet both format and content requirements listed herein. 6. Bidders may be required to provide the District with samples each of the specified item for evaluation and inspection for a period up to one week. 7. The District reserves the right to reject any or all bids of any part thereof, or to withhold the award and to waive or decline to waive irregularities in any proposal when it is determined to be in the District's best interest. 8. The successful bidder(s) is expected to enter into a Standard Agreement approved by the Board of Trustees of CLPCCD, which includes the Standard Purchase Order Terms and Conditions, which are included herein. 9. Under a subsequent contract, Contractor will be required to submit any and all technical manuals per each type of equipment described in this Bid. 10. The District reserves the right to make a partial award to multiple vendors, so as to best meet the needs of the District. SPECIAL INSTRUCTIONS 1. Contractor must set forth herein of any modification(s) or exception(s). District reserves the right of refusal and will return all unauthorized substitutions. 2. Questions from bidders will be answered promptly by the District. The last day for questions is May 15, 2007 at 2:00PM. Questions shall be directed to Eva Chiu, Buyer, Purchasing and Warehouse Services Department in writing, via facsimile Fax: (925) or echiu@clpccd.org SECTION I RESPONSIBLE BIDDER AND REPONSIVE BID In order to be determined as a responsible bidder submitting a responsive bid, bidders must comply with all requirements in all sections of this bid, including provision of the following: 1. Complete and submit Attachments A and B with your bid. 2. Provide evidence that your firm is authorized to sell, install, maintain and repair A-Dec brand Dental Chairs. Page 7 of 15

9 SECTION J- POST SALE SERVICES The District requires any firm awarded a purchase order as a result of this Bid provide inservice training to District staff, on-site at Chabot College. Training shall be complete to the extent it is sufficient to familiarize staff with equipment operation, features, safety, adjustments, trouble shooting, maintenance and repair needs. The successful bidder shall meet the following requirements Provide authorized technical support for repair and maintenance of the dental chairs and operator chairs within 24 hours of a request for service; Provide a thoroughly trained service representative that will be available to respond to requests for service within the 24 hour time period stated in the previous bullet; Have a service center within a Fifty (50) mile radius of the Dental Clinic facility; and Provide a warranty for labor at no cost to the Dental Hygiene Program of the College District for a period of not less than one (1) year from the installation date. (End of Section) Page 8 of 15

10 SECTION K - GENERAL PROVISIONS FOR WORK AND SERVICES General Provisions for Work and Services For Purchase Order # This Agreement for services is made by and between (Contractor) and the Chabot-Las Positas Community College District (District) as of. 1. TERM: This Agreement is effective and will continue until. The agreement may be extended if agreed to in writing by both parties. Either party may cancel this agreement with 30 days written notice to the other party. 2. SERVICES: Subject to the terms and conditions set forth in this Agreement, Contractor shall provide to the District Services as described in the Purchase Order and/or Contractor s bid proposal and made a part of this Agreement. Contractor agrees to keep the District regularly informed of the progress of work performed under this Agreement. The District has the right to approve personnel assigned to perform these services. 3. COMPENSATION: The District will pay Contractor as specified in the Purchase Order. No increase in amount or scope of services is authorized without formal written amendment to this Agreement. 4. TERMINATION: This Agreement may be terminated by the District, at its sole discretion, upon ten-day advance notice thereof to the Contractor or canceled immediately by written mutual consent. In the event of termination, Contractor shall be entitled to compensation for services performed to the effective date of termination. 5. CONFLICTS OF INTEREST: To avoid any potential conflict of interest problems, Contractor represents that it does not employ or retain the services of any spouse or family member of any District employees, nor has it furnished any financial compensation for the pursuit of business with the District. 6. INDEPENDENT CONTRACTOR STATUS: This Agreement is by and between the District and an independent contractor and is not intended to and shall not be construed to create the relationship of agent, servant, employee, partnership, joint venture, or association. As an independent contractor, Contractor will be solely responsible for determining the means and methods for performing the services described herein. Contractor will assign the Contractors it proposes to use. Contractor shall be responsible for deducting all federal, state and local income taxes, FICA and other charges, if any, to be deducted from the compensation of Contractor s employees. Nothing in this Agreement shall be interpreted as creating or establishing a relationship of employer and employee between the District and Contractor or any employee or agent of Contractor. Each and every person providing services to the District under this Agreement shall, at all times, remain an employee of Contractor. Contractor s employees shall not, at any time, or in any way, be entitled to sick leave, vacations, retirement, or other fringe benefits from the District, nor shall they be entitled to overtime pay from the District. Contractor is solely responsible for paying all necessary State or Federal tax for itself and its employees. The District will make no State or Federal unemployment insurance or disability insurance contributions on behalf of the Contractor and/or its employees. Neither Contractor nor its employees shall be included in the classified or faculty service, have any property rights to any position, or have any of the rights an employee of the District may otherwise have in the event of termination of this Agreement. The District further understands and agrees that Contractor is engaged in an independent business and the District shall have no right to direct or control in any way or to any degree the manner of Contractor s performance hereunder. Contractor understands that it is not authorized and shall not make any agreement, contract or representation on behalf of the District or create any obligation, express or implied, on the part of the District. Page 9 of 15

11 7. NON-ASSIGNABILITY: This Agreement is not assignable by the parties hereto without the express advance written consent of the other party. If assigned, this contract shall inure to the benefit of, and be binding upon, the heirs, legal representatives, successors and assigns of each party hereto. 8. INDEMNIFICATION: The Contractor shall defend, save harmless and indemnify the District and its officers, agents and employees from all liabilities and claims for damages for death, sickness or injury to persons or property, including without limitation, all consequential damages, from any cause whatsoever arising from or connected with the operations or the services of the Contractor hereunder, resulting from the conduct, negligent or otherwise, of the Contractor, its agents or employees. The District shall defend, save harmless and indemnify the Contractor and its officers, agents and employees from all liabilities and claims for damages for death, sickness or injury to persons or property, including without limitation all consequential damages, from any cause whatsoever arising from or connected with the operations or the services of District hereunder, resulting from the conduct, negligent or otherwise, of District, its agents, servants, employees or subcontractors hereunder. 9. FORCE MAJEURE: Neither party to this Agreement will be liable to the other for any failure or delay in performance under this Agreement due to circumstances beyond its reasonable control including without limitation, Acts of God, accident, labor disruption, acts, omissions and defaults of third parties, and official, governmental and judicial action not the fault of the party failing or delaying in performance. 10. COMPLIANCE WITH APPLICABLE LAWS: Contractor and any subcontractors shall comply with all laws applicable to the performance of the work hereunder. Contractor represents and warrants to District that Contractor and its employees, agents, and any subcontractors have all licenses, permits, qualifications, and approvals of whatsoever nature that are legally required to practice their respective professions. Contractor represents and warrants to District that Contractor and its employees, agents, any subcontractors shall, at their sole cost and expense, keep in effect at all times during the term of this Agreement any licenses, permits, and approvals that are legally required to practice their respective business or profession. In addition to the foregoing, Contractor and any subcontractors shall obtain and maintain during the term of this Agreement valid local business licenses that are required. 11. NON-DISCRIMINATION: Contractor agrees that it will not unlawfully discriminate on the basis of race, color, religion, gender, national origin, age or medical condition, sexual orientation or marital status or any other characteristic protected by law in the delivery of programs or services set forth herein. 12. WARRANTY: Contractor shall diligently and carefully perform all work required hereunder in a good and workmanlike manner according to the standards observed by a competent practitioner of the profession in which Contractor is engaged in the geographical area in which Contractor practices its profession, and shall furnish all labor, supervision, materials, equipment and supplies necessary therefore. 13. INSURANCE: Contractor shall at all times during the term of this Agreement, or any extension thereof, maintain comprehensive general liability insurance coverage in the amount of $1,000,000 per occurrence and in the aggregate for all claims made during any one policy year. Contractor shall, upon request of the District, provide proof that the services provided are covered under its policy and that the District is named or fully covered as an additional insured. 14. WORKER S COMPENSATION INSURANCE: Contractor agrees to comply fully with all provisions of all applicable workers' compensation insurance laws, and shall procure and maintain in full force and effect worker s compensation insurance covering its partners, employees and agents while said persons are performing services pursuant to this Agreement. In the event that an employee of Contractor performing this Agreement files a worker s compensation claim against the District, Contractor agrees to defend and hold the District harmless from such claim. Page 10 of 15

12 15. ENTIRE AGREEMENT; NO WAIVER: This Agreement constitutes the entire agreement between the parties hereto pertaining to the subject matter hereof and supersedes all prior agreements, understandings, negotiations and discussions, whether oral or written, of the parties, and there are no warranties, representations or other agreements between the parties in connection with the subject matter hereof, except as specifically set forth herein. Except as otherwise provided by this Agreement, no supplement, modification, waiver or termination of this Agreement shall be binding unless executed in writing by the parties to be bound thereby. A waiver of any breach or any of the covenants, terms or provisions of this Agreement shall not be construed as a waiver of any subsequent breach of the same or any other covenant, term or provision. When there is a conflict between the Contractor s bid proposal Terms and Conditions and the District s, the District s shall supersede OWNERSHIP OF WORKS FOR HIRE: All matters produced under this Agreement shall be works for hire and shall become the sole property of the District. Said works cannot be used for any other client or purposes without the District s expressed written permission. District shall have all right, title and interest in said matters, including the right to obtain and maintain the copyright, trademark, and/or patent of said matters in the name of the District. 17. GOVERNING LAW: This Agreement shall be governed by and construed in accordance with the laws of the State of California. 18. VENUE: In the event that either party brings any action against the other under this Agreement, the parties agree that trial of such action shall be vested exclusively in the state courts of California in the County of Alameda or in the United States District Court for the Northern District of California. 19. NO THIRD PARTY BENEFICIARIES: Nothing in this Agreement shall be construed to create any duty, standard of care, or liability to anyone other than the Parties to this Agreement. No one is an intended thirdparty beneficiary of this Agreement. 20. ATTORNEYS FEES: If a party to this Agreement brings any action, including an action for declaratory relief, to enforce or interpret the provision of this Agreement, the prevailing party shall be entitled to reasonable attorneys fees in addition to any other relief to which that party may be entitled. The court may set such fees in the same action or in a separate action brought for that purpose. 21. CAPTIONS: The captions used herein as headings of the various paragraphs and subparagraphs hereof are for convenience only, and the parties agree that such captions are not to be construed as a part of the Agreement or to be used in determining or construing the intent or context of this Agreement. 22. COUNTERPARTS: This Agreement may be executed in any number of counterpart copies, all of which shall constitute one and the same Agreement and each of which shall constitute an original. 23. SEVERABILITY: If any of the provisions or portions thereof of this Agreement are held to be unenforceable or invalid by any court of competent jurisdiction, the validity and enforceability of the remaining provisions or portions thereof shall not be affected thereby. Page 11 of 15

13 ATTACHMENT A STATE OF CALIFORNIA COUNTY OF NON-COLLUSION AFFIDAVIT I,, being first duly sworn, deposes and says that I am (Typed or Printed Name) The of, the party submitting (Title) (Bidder Name) the foregoing Bid Proposal ( the Bidder ). In connection with the foregoing Bid Proposal, the undersigned declares, states and certifies that: 1. The Bid Proposal is not made in the interest of or on behalf of, any undisclosed person, partnership, company, association, organization or corporation. 2. The Bid Proposal is genuine and not collusive or sham. 3. The bidder has not directly or indirectly induced or solicited any other bidder to put in a false or sham bid, and has not directly or indirectly colluded, conspired, connived, or agreed with any other bidder or anyone else to put in sham bid, or to retain from bidding. 4. The bidder has not in any manner, directly or indirectly, sought by agreement, communication, or conference with anyone to fix the bid price, or that of any other bidder, or to fix any overhead, profit or cost element of the bid price or that of any other bidder, or to secure any advantage against the public body awarding the contract or of anyone interested in the proposed contract. 5. All statements contained in the Bid Proposal and related documents are true. 6. The bidder has not, directly or indirectly, submitted the bid price or any breakdown thereof, or the contents thereof, or divulged information or data relative thereto, or paid, and will not pay, any fee to any person, corporation, partnership, company, association, organization, bid depository, or to any member or agent thereof to effectuate a collusive or sham bid. Executed this day of, 20 at (City. County and State) I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Signature (Address) Name Printed or Typed (City, County and State) ( ) (Area Code and Telephone Number) Page 12 of 15

14 ATTACHMENT B DRUG-FREE WORKPLACE CERTIFICATION I,, am the of (Print Name) (Title). I declare, state and certify to all of the following. (Contractor Name) 1. I am aware of the provisions and requirements of California Government Code 8350 et seq., the Drug Free Workplace Act of I am authorized to certify, and do certify, on behalf of Contractor that a drug free workplace will be provided by Contractor by doing all of the following: A. Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensation, possession or use of a controlled substance is prohibited in Contractor's workplace and specifying actions which will be taken against employees for violation of the prohibition; B. Establishing a drug-free awareness program to inform employees about all of the following: (i) (ii) (iii) (iv) The dangers of drug abuse in the workplace; Contractor's policy of maintaining a drug-free workplace; The availability of drug counseling, rehabilitation and employee-assistance programs; and The penalties that may be imposed upon employees for drug abuse violations; C. Requiring that each employee engaged in the performance of the Contract be given a copy of the statement required by subdivision (A), above, and that as a condition of employment by Contractor in connection with the Work of the Contract, the employee agrees to abide by the terms of the statement. 3. Contractor agrees to fulfill and discharge all of Contractor's obligations under the terms and requirements of California Government Code 8355 by, inter alia, publishing a statement notifying employees concerning: (a) the prohibition of any controlled substance in the workplace, (b) establishing a drug-free awareness program, and (c) requiring that each employee engaged in the performance of the Work of the Contract be given a copy of the statement required by California Government Code 8355(a) and requiring that the employee agree to abide by the terms of that statement. 4. Contractor and I understand that if the District determines that Contractor has either: (a) made a false certification herein, or (b) violated this certification by failing to carry out and to implement the requirements of California Government Code 8355, the Contract awarded herein is subject to termination, suspension of payments, or both. Contractor and I further understand that, should Contractor violate the terms of the Drug-Free Workplace Act of 1990, Contractor may be subject to debarment in accordance with the provisions of California Government Code 8350, et seq. 5. Contractor and I acknowledge that Contractor and I are aware of the provisions of California Government Code 8350, et seq. and hereby certify that Contractor and I will adhere to, fulfill, satisfy and discharge all provisions of and obligations under the Drug-Free Workplace Act of I declare under penalty of perjury under the laws of the State of California that all of the foregoing is true and correct. Executed at, 20. (City and State) this day of (Signature) (Handwritten or Typed Name) Page 13 of 15