品
T
機
鳳
朧
」
棚
聯闇猟撤欄謬熾
er Charges incured
",or any oい
delivered
Minimum number of cases or poun(h fo be
Additional fue fi any
br
edl
shiPrre
nt: 7OO
otfrer warehouse disticts:
Lead tirne ror deliverio # of
day's
l? #ofweek's.-.=--
inturmation below:
Please provide any other additional
vendor Nama
Authoized compan
sunatuttdcOmpanyOmlJ:__』
yoffid'sNane'
レ
イ
Et'l bl"o't'f
Z乙
惚
空
峯
維
一
_一
二
一
一
一
―
一
―
一
一
Pageτ 面
FELONY CONⅥ CT10N NO■ FiCAT10N
State of Texぉ Le9blalive Smale Bi‖ No.1,Seclion 44.0鉾 ,Noliblion of Cnmitt HbtOry,subseclion(a),
stab“ a person or bugness enlり hatentes hto aoontatwim asch001 dstictmustJve advance nolceto
entt haS been∞ n宙cted of a febny.´ 丁he
he dbttt r he persOn or an owner or operabr of he bllsi舶
nolice must hdude a generaldesc‖
pお n of he∞ ndtt resuttng“h he conuclion of a uony."
Subsedon(b)StateS・ a school dbtttt may temhate a contract wilh a person or bushess en」 ty rtne dstrict
detemines hat the person or budness entv failed to give nolice as reqdred by Subsecton(a)0「
misrepresented he∞ nductresuning ln he contton。 ■ne disttct must∞ mpensate the person or business
entt fOrservices perfomed beFore he teminalion ofhe∞
ntrad."
Thb Nolioeヽ Not Required of a PuЫ idy Hdd CorpOralon
Vendors Name_ρ
/-9″
胤基 んι´
Au詢o虚 ed COmpmy Omidis Name(Pdnted〉
巨 ■1
ムス
ヵ′
“
A. My frm is a publidy held corporalion:herefore:this repoding requirelTlentis not app‖
cable.
SbnatureofCompany Oncial
B.Mylmに
notowned noroperated by anyone ttm has been∞ nvind Ofafebny.
Signature of ComPanY Official:
C. My firm b ot rned or operated by tre following individual(s) who hadhave been convicted of a fulony.
Name of Felon(s):
Details of Conviction(s):
Signature of Company
fficial:
Comdete and retum utt ProDOSJ
RFP#201410
FULL uNE GROCERY「 EMSWAREHOttSE,artt shぃ
Page 17 o129
Requestfor ProDOSal
ATrACHMENT A
NOTARIZED STATEMENT VAHDATNG「雨 PO面 こ51TENTSNONCOLLuSO世
…
To:
Region 10 Education Service Center
not been,for s快
monhs,diは 町 Or hdtty COncemα
pnces ofserv ces pmposed,Or has notinluenced any person to pЮ
pOse or not purpose thereon
EMS WAREHOUSE,DIRECT
i have read lhe compbte PЮ posal RFP♯ m14‐ 10 FULL LINE CROCERY I‐
y of al mfOmaton∞ ntamed m the
SHIP fOr member dヽ いctS h Mutt Regbn Co‐ Op and tt he aco」
“
hposal
Authorized Vendor
fficer
Typed name
NOTARY PUBLIC
4‐
ステ
L`lヶ ィィ _生 竹
ジI万 フ ンタ
J MADDOCK
d刹
cOm口 お and rdum wtt Pro● osJ
曜器職邸:
」
ユ
イ
ング
マ
/ノ
`tフ
而
40
画 面 雨 雇 雨 而 RlSwAREHOUSE DlreCt鋪 o RFP12044‐
Page"da
Certif ication Regarding Lobbyin g
and Contrets Exceeding $100,00C in Federai
@ments.
Funds.
into his transaction and is imposed by
Submisson of bis certitcaiion is a prercquisite for making or entering
which reliance
,dion rssz, l'ifle 31, u.s. code. Th'ts ce ification is a matedal re$esenbtion of fact upon
file
the required
person
to
who fails
iransac{ion was mde or entered into. Any
for erch
subiect b a cMl penalty of not less han $10,000 and not more han $'1([,000
;ilb..d il.. tli
ffia*-tr,,.iiur
such failure.
The undersigned certifies, to the best of his or her knowledge and belief'
hat
(1)NoFederalappopriabdfundshavebeenpailofwillbepaidbyoronbehalfoftheundeBigned,to
p"*n for infruencing or attempting to influence an offcer or employee of any agency, a Member of
i,iv
C,inri"", an .m." or dpbyee ot congress,
i. i*rru,r,s.i r reoeratconiract ttre niaking
or an empbyee oJ a Member of Congress in connection with
of a Federalgrant, the making ol a Federal loan, fre entering
modifcation of a
agre€rnent, and the exterision, mntinuation, renewal, amendment, or
lnO a
Federal mnbacl, grant, loan, oI cooperative agreernent
..fi"W.
(21
paid to any peron for
lf any funds otler than Fderal appropriated funds have been pairi or will be
o[
Congms, an offi6r
Member
a
of
any
agency,
iniuencing oi attempting b influence an offcer or empbyee
Federal grani or
wifi
tris
or employee ol congresti, or an empbyee ol a Member of congress_in connection
'disclosure
Form to
agrear;nt, t\e undersigned shall complete and submit Standard Fofin.LLL,
coop;t,e
Report Lotrbying," in accordance with its instuc{ions.
(3)
the award
Ttre unders(1ned shall require lfrat the larguage of this certificatjon be included in
that dl
and
tiers
at
all
appropriate
ioc.uments for all covired subawards exceeding $100,0m in Federalfunds
subGcipients shall certify and disclose accordingty'
Rh,/.,
A"L.-,//-
s.,
Name/Address of 0rg anization
Er;l<
t-L^.L/Q
Name/Title of Submitting Official
Signature
Comple{e and lelunl-Uath EtlPQsa!
i[firile cnocenv ,reus tllanEHousE,
oked shp RFP { 201+10
Page 18
ofa
Aπ ACHMENT B
￨
SUSPENSION, tre prospective vendu
ln mordance with Execuiive order 12549 DEBARMENT AND
it nor its principals is presenily debaned' suspended'
certifies by submission oifi',i. Proposal, trat neiurer
from parlicipating in this transaction by
proposed for debarment, oectareo'ineligible, or voluntarily exduded
any Federd dePartment or agency,
any of ure statenents of tris certification, such
wtrere the prospective ofieror is unabre to certify to
participant sfrall attadr an exptanation to tris Proposal.
il;p*il
when this
of tre fact upon wiricfr reliance was placed
The certification in this dause is materid representation
an
entered
knowingly
into. rf it b rater determined trat the prospecrive ofieror
transaction ,r..
Mutti-Regional
ffre
"nt
reneoles avairabb b h; Federd Govemment,
enoneous certification, in addition h otrer
suspension and/ordebarment.
coop may pursue ,nv .Jurr.*itable remedies, induding
rj
whom this
provide immediate written nofrce to the person to
Additionapy, the prospective vendor shail
when
erroneous
\yas
pnoposar is submitted ii at any time tre p*p".ri* ofieror reams trat its certification
submittedorhasbecomeerroneousbyreasonofdrangedcircumstances.
Theprospectivevendoragreesbysubmittingtrisformtrat,shouldtreproposedcoveredtransactionbe
person or firm uf,ro is debaned'
anV tttnt*en't9.*'I
entered into, it shall not knowingly enter into
t
ii.ig;r., oi;oruntariry exdui.o tro*
suspended, decrared
autrorized by tre Multi-Reghnal CeOp'
participation in this cowred tansaction, unless
tre previous paragraph, if a prospective ofieror in a covered
Except for transmlhns authorized under
who E suspended' debaned' ineligible' or
o into a transaction-*itf'
transactbn knowingly
Federal
"nt
in aooition to other remedis avairabre to tre
voruntariry excruded frun participation in tre
and/or
suspension
pu*" and a[ availabre remedies, induding
Govemment, tre Mutti-Regiond coop rry
t pb*i
tr*.*ti-,
debarment.
Potenjal 1/endo「 Narne:
Ti[e of Autrorized Represenralve:
Uf
Ma面 ng Address:
SSnature:
COFnplete and retum囃 h ProDOSal
D'rect StrF RFP # 201+10
P39e20 of"
unl日 d SahE and SerVLes,LC
PH:201・ 251300
FX:201・ 251・ 6507
CONFuCT OFiN■ RST QUES■ ONNA:RE
For vendo「 o7● ther per"nd● lng buslness wlth:oca:g●
vernme喧 entity Fi:当
￡ 】∠
5
likcly to receiv. taxrblc
k tfie local tovemment officea na m.d in this 3lction r.
om. irom the filer of t,r! quetdonnalre? Cl Y- E
rsrh! fitc' of t Equetionn
sction of
th!
,local Eorrmrnent l
ts
Ali,lntor *A
local go\rlanmcnt
*.n.income
I
rrorn
or.tthe
oftccr namg[]6 thh scction AltD the tex.bh in.ome
.nt\? A "-
f
ls not from
A
th. fihr of this qu6ti
-r}.t, or rr.. busanes. cntity tfiet the
" "n.r/n"**.
an officer oi di.cctor. or holdr an own.rship of 10 parcent or
orflcr servg,/s
al govamtnant
,re? O
yn flrfi /
Oesaribe each
or buCrcss relation3hlp.
/
6
LtC
A●
FULL LltE GROCERY「 EMS WAREHOuSE,C rectSll● RFP#2014‐ 10
1/1272● ●
5
●
プ國 工
pee 22 o129
嚇 ,LC
PH:露 1・251300
“
251・
製
FX:201‐
unlbd sabs and SeⅣ
「ACHMENT C
A7‐
"7
ONOIAIRE
'AITEREST
dolng
btrrin6t -tth l*l go"t-tntnt'l
oth.t
For vrndor or
Pcrson
COI'IFIICT
qUES
OF,
@ier:76cf
Go\remment Codc by a parson doint hlsineas
FORM
i:€ io<.I"ntiry
whh the 8ov*nmantal entiv'
CIQ
OFFIC[uSE ONtV
qucstiodn.ire mtrst bc ilcd witi lrrc rcco.ds ldmlnktrat6r ofthe locll
govemment not l.t r dlan fhe 7th business tLy lftrr tl1! date the person b'come'
iware of facs that requit! the stateoentb bG 6lcd. see Scction 176 006, tocal
By law this
Gov.mmlnt
A
Codc.
pcnon codmitt an offlnsc
if
lfi? pcrron vbLtls s.clion
Code. An offensa undcl thas sa<tion lt
1吹
a
176 0o5;
bc'l
6oYemm'-nt
cLasC mitdcmeenor'
耀こ
賢 饗毀搬鰹二澤半
躍墨≧翌盟墨買としC
『
_
□ CheCk thL box r vou are nlln3 an update to a pr^`uJy rLd qucstlonnJre
0●
1こ
W requtres■ at"口 ■にan updat“ ∞ mpleted ques● ∽ naiに
wnn“
appropnate Fling
ty dぼ rbedin sectOn 176 0"● ).tOC爛
hter than Septen・ be,1● Fthe,o「 fOr wHch an tcい ′
Odr,
Is
p.idi'lt..d
tEcqtrcs krcomplata
tt!
rbt la!! $tn
7th buCn
!.
oa lnacarrata-)
day after
fie dalr dl. o'idntltY tfl'd
に
満
い
tal en判
3
to alocal government o― Ofttr g― rnmental en● ,wlth resI
AND desc● be the a綸 !iatton● r bln― reladonsh●
.
E選ぶ
昇魏
ゞ
/_
4
Nanne cach local government
I=よ
電
『
lenu″
ッ
ppoints o. etr'ploys local tovcmdent officers of the
questlonn.lt" b filcd AND describe thc affiliation or bl.6inc's
ffio
tiis
a
/
AI● pt● d■ 1/02′ 0●5
ばL山
Disc10m“
嚇 戴
織
m出 ¨
調器 ず
躙
吊鑓普
LI
-
3 Rcportl,p●
Adion'
..bid/offer/lpplisrioB
u. initht a*ud
2. Ststus of Fcdcr.l
of Fedctal Action:
U
-
a. @ntract
6. grrnr
Approvcd bY
=器
OMB
1. Typ€
…
:
□II思
『 臨n"
c. Pos(_awrtd
c. coopantivc iSrccmoat
d. loan
c.looD gnlran&e
I loan hsurencc
5 1f RepOrtinB Ellllty in No 4 1ぅ
4 Neme and Addre6S Of RepOrtin3 Endtyl
□PttC
and AddrcsS Of Prine:
□lttr3fk"。 w・
kogrstn NalEc / DascriPlion:
6. Frateril Depinment / Agcncy:
litinaiviouat.
tasr name, firsl nsde'
me“
ソ
ii-Erm
heck響 11蟹
“
of PrYment ("heck
cIじ
MI)l
品:」 I話 lsS・ ふ
ffe re口
13 Type of PaymentrCheck a“
? !. retainat
? b. one_liln. fcc
:∬ ;レ
omヽ 0
●
10aXは
ヽname,
that apply):
? c. connksion
? d. cotrdngclt fc'
rll
? a caSh
?b in‐ kind,sPCary:
? c. defcrred
? f. orher: specify:
f]Ir"r*.a
ot to br Pcrfoflnrd and
lndicatcd in lrctn 11:
)
"f-ffi-,lr"l,rdfi "fil(s),
Shcet(3) SF-I-LL-A,
enptovec(s)' or Membe{s)
if n'ccssary)
Red(s)lF LLL‐ Aa● achCd'Yes 'No
帥
_^.t.ri"l
:咄 出嚇
欄 鋤聾b'
Ptaccd
,"o,"s"nt",ton of {act upon wnrc0 rclia;ctwas
1澱
;・
ffi fi i";;,il;; ;*i: :l'-(o l,l u?'.11',',:!:+T'T1"',X',1*;x
ri r'\
disclosure is lequired Pursuenl
semian!-uauv
consress
in.'
i,
IJilii'ipl"l,li
Ti.Il,:"J;::"'
l:H'Jl[$fr "J:Tt+];f '"':l'ii:i:iqlJ'i:iit"ji:;ilf :
[il;;;.:;;
a,oA'ooo ror cacn such railurc'
EMS vVAREHOtlSE.Drecl
―
AuthOrized Fot■ ●Cal Rep:●
S● ndard From‐ I.LL
Sh"RFI#2014‐
10
Paoe 23 ol
E
duC,iOロ
PROPOSAL FORM
Ibr
CERTIFICAT10N RECARDl‖ G
TmSFAMlLY CODE
:by Sa“
驚露
合
調翼盟鑑麟棚 柵 鷺
'ActS,ん
に
ttR RS 1993i,郡
晦Ы
J tt folbttng afndav■
∞ntact
ADDRESS
PRINTED NAME AND TrTLE OF AUTHORIZED REPRESENTATⅣ
■
SlGNATURE
Co一
LlNE
rEMO WttHOuこ、●lrd
ship prp輩 2044_10
Paoe b Or29
ms ha manufacmtt mdb ds"bute food O熱
日
需糀謂督
、
:訓障窯鮒露出
t群 鷺
峨縞 認轟 鰐胤 鰐蹴総
器 1榊 蹴暴1躙 還1』麟 鵬 朧ぶ織淵鮮財
n.
epamentOf Healh lTDH):
Texas Depattent of Heab
Manuractured Food O市 biOn
l100W饉 綱鰤Strd
Au30n TX 7879■ 31"
18881987111
A∞ py
Grne
oflhe Food WhObSa:● r LiCOnse mustbe induded wtt PЮ
anO
pOSal
fiUe ot nuhorized Representative
Proposal: Yet
Copy ot Food wholesaler License inchrded with
*@....---
Comdete and retum哺 th
FULL LINE CROCERYITEMSヽ ″想 EHOUSE,Dred Ship RFP#201410
OSal
PЮ ●
Page 26 oF29
RECEIVED
MAY 2 9 2014
8uSiNESS SERVICES
Clean Alr and Water Act
issued puBuant to the
l, the verdor, am in compliance witr all applicabb standards, qI!98 oI Iesulations
ilean Air Acl of 1970,
U.a.C. i368),-E
as nmended (42 U.S.c. 1857(hD, Seclion 508
*utve
ofhe clean
Water Act, as amended (33
grder 117389 and Environmenhl Proteclion Agenry Regulation, 40 CFR Part 15 as
required under OMB Circular A'102,
Attachment
States
o, Paragraph 14 (1) regarding reporting violations to the grantor agency and to the United
Envircnment Protection Agency Assistant Adminislrabr for the Enforcernent-
Potential Vendor Nam€:
″
MJ‖ ng Addressi
ルん
2s44?. stc
`Ч `2'
鈎 MLC
Comdete and rmm wlth Pr● ●osJ
日」LL
LINE CROCERY
ヽ
VttREHOUSE,D熙
RP F2044・ 10
Page 2ア of29
CERT:FICATЮ N OF PROPOSAL SPEC:FiCAT10NS「
RFP抑 14・40
ERMS&CONDIT10NS
:朧 aCCepted h輌 鴫
祠 躙朧
鼻
聰 、
俳
coMPttY NAME
′胤 る
,珍
∠こ ―ノ/Q′
tO Sue・ ayes
ノ
Addttss
洗
生 墨 必 ■ 」 t出 弟
cじ 見
需惚
一
聯鰍 '7・
vendor
冴
Typed Nal,…
ZI「 gイ ″ S
夕 7助 じ
均
Jこ Z写静 一
―… … …
……
…
RESIDENT VENDOR C[RTIFICAT10N
h orderlor prOposd 10 be consdered,he fo‖
蛹 w infomaton mutt be pЮ vded FJに re to cOmdete mav
麒 朧
躙 轟選
fぷ出鵠
ompanyis a“ resident vendori
Signature
躙酬 酬 僻 1憫 [脚躙 置涙
剛
;
Company
City
０ ０
pl=l:i1T:S]:
!nh06e plincipd
Does your'residence state' requiE vendors
vendols wno6e [esf,lElr{./E lrcre rD ure II話
.rrtti.,z "Resrdence state' Ireans lhe staie in r6ich
: :H"'i#1:tffiitl
ざ
網oqrrE
∬ξ
鵠:‰冨高滞よ
ド獅￨"lli型fte史四聖
鯛lEl空 i蹂糖
iirprlriii,
YE漁
NO
悪扇
hat
l ce耐ゾ
Typed
Name
χ
lagθ
principal place of business is located
___=%
∞mCt
htabOVe mbmtton、
〃
POSitiOn
´
]
compa■ y Name
Fage 28 of
FUL UNE GROCERYITFMS WttEHOUSE,Dlrect Shlp RFP#"1410
I
PROPOSAL ACKNOWLEDGMENT
FULL LiNE CROCERYITEMS WAREHOuSE,DlRECT SHiP
IRFpr櫛 1■ lq
TO:Educaton Servlce Center Regbn 10
臨itts‰ 肥∵開冨躙 鶉
blony Con■cton Notce or Clean Ar and Waterた 0
cable state or federa!laws
傲榊i榊撚隅]隣絋￨
獣贈
胤轟‰朧蹴 nl:蹴 s継 謎
肥鵠澪柵 織 は
:調 器
霧懲
1
iξ
Name of Firm:
Datel
slgnature:
Name/Ti{e:
′
レ
イ
し
レ
島
‐
‐
′
′
ζ
L´′ タ
=
rirn'sxar*s:
/O&r '5477, Lt*b& ζ夕 ″
25'4
アイ′
`イ
Phone #:
Fax #:
ss。「FedlD l:
PROPOSAL ENVELOPES SHOULD BE PLAINLΥ
MARKED:
400 East SPring Va!:ey Rd.
眈 hardSOn,Texa9 75081
DUE:Thursday,May 29,2014 at 4:30 pm
Comdde and retum輌 OroDOSJ
面 面 蔽 蘇 乃SE Dred鮎 I RFP#
一
Paoe 29of29
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