RECE:VED MAY 29 20綺 BuS:NESS SERViCES SPECIAL CONDIT10NS FOR DELiVERiES ‐ awarded venloS that mo鴨 Shoutt n be detemined by eilherthe Mu晰 Re9bnd CO‐ Op=KLLEEN lSDJo「 than once denVery a weekto any ofthe dЮ O Sites wimin the school Districts is necessary,please lst any addllionalfees beloⅣ .Be specttc as to fOrrnulas′ iees,Or any othr chargesincu幅 , Minimurn number ol cases or pounds to be delivered each Additional iee if any forotherwarehouse districts: Lead time for deliveries # of daY's ノθ f ofweeKs below: Please provide any other additional information Vendor Auhonzed ComPanY Official's Name:. sicnature of COmpany OttCiali Co m 雨 plels tlld-rgslr.:uith.-Prg Page 16 of29 FELONY CONViCT10N NOTIFiCAT10N 蹴 ‖ 悩 Ⅷ躙 T朧:絣 悪 撃 掛 i欄 孵 聯 State of Texas Le9も ねIve Senate Btt No.1,Secibn 4.034:Nottcation of Crimmal Hb10ry,Subseclon綺 ), notice rnustinclude a general descriplion ofthe conduく f tte d螢 nd ntract with a"mn tt bugness entlャ lFl鵠冨富 嵩鴨 器甚:∞ 綿』 職 篤滉 寵:麒 鷺織ittu彙 ∬ 胤懲 ::1縫 臨;薔淵 ri淵 騨 私 ::麟 ::鼎 hecontact." This Nolcels Nd Requk対 of a Publicly Held Corporalon Vendors Name Auhorized Company Official's Name (Pnnied): A,Mylmも a puЫ Lv hdd COrporalioni ttereb",hヽ rep° ttng requiement b not applcab燈 , Signature of ComPanY Cfficiai: B. has been convicted of a felony' My finn is not owned nor operated by anyone who Signature of ComPanY c. fficial: individual(s) who hadhave been convicted of a felony My frnn is owned or operated by the following Name of Felon(s): Details of Conviction(s): Signature of CcmPanY Oficiai: Com● ete and return with ProposJ FO生 しNE ёROCERヤ 雁 MSttREHOUSE,D面 勁 ip RFp髯 Page 17 of 29 "1410 6Zio 8t atud 0 t-p toe f dJU drqs perp'3snoH;wu sv,Jsrl AUf 5c!0 lNrl lln J IPSO画 面dЧ :!“ ulnla弓冗ぼ o101du10Э wF平載司ず ヘス ■ 式 1 ・ 6upoooo 角 Ilo leЧ l pue sJo!l aleμ doJdde lle w spu町 peMo o嗜 ul popnpЩ eq uo123」 り00 │● osqЭ ョp puじ 亀ツ00‖ じuS suadloo」 qns JOpeJ u1 000`001s Oulpoooxo spJBMeqns peJoA00‖ e Jq stuetunoop (3) 06en6uq oり l● 叫 OJInbeJ‖ りЧs peuaS」 epun。 牡 qЧ :10 ・ suor・ DttISu Si曝 ぃ 00Wp10000 Ч.:6uFqqO¬ 口 剣 q翻 oJ ansop,p.11¬ 1‐ Ш OJ peputts lШ qnS puB tterW∞ ‖eЧ s peuo創 epun eЧ l tuoШ 00J艶 oAleJed∞ “ Э 01dШe Jo o`sse」 6じ oo lo“■ 」 o lu8」 61e」 epeJ sit♯ Ч ttM u0100uuoo ul sseJSuo0 1o」 oqttleltt e lo ooス oldШ e u● 」 」 o6ulouonJul ul q 6uldtuell● o」 oou10 ue eOuen」 J001ル O ue tsseJ6uoO lo loqulew e:Aouo6e Aue lo ooXolduJe」 ue ll (z) q uosedス ue q ped eq‖ !ハ 」 o pled uooq oAじ ЧSputt peleμ dOjdde F」 opeJ ueЧ l」 oЧ lo spunょ κ 」 ・ luetuooJ6o oAleJeCoα )Jo`ueOl`lueJO=lЭ elluoo l口 epeJ `uolenuluoo luolsuelxo oЧ l pue`luoulooJ6● oAleledooo e olu! e lo uolooじ lpOtu Jo`luoLupuOuJじ `lu361elepoJ 8 1o 6明 】BШ oЧ l 1031U00 100peJ e jo 6ulpleM8 0■ 6uμ eluo oЧ l:u0011劉 opeJ elo 6Щ 】euJ o颯 `le爪 oue」 Чl!M uolloouuoo u!ssoJ6uoЭ j● 」 ●qLuO肉 e lo oo人 oldШo uo」 o`sS創 6uoo lo ooκ oldLU0 10 J00聾 O ua lsseJ6uo0 κue ue lo oJoldШ o」 o loo"o ue oЭ uonじ ul o1 6uldtuelle」 o6ulouenじ し │』 ol uosIOd 10 Jequo側 elバ ouo68 κ q tteuattepun eЧ 1lo leЦ eq uo Jo lq ped oq熙 触 」o ped uooq eAeu Sputt poleμ dOdde l口 epe=oN (I) :le哺 =lelleq pu● o6pelMou、 loЧ Jo slЧ j0 1Seq oЧ l 020 Jq 000`00LS ueЧ :OJOtu lou pu8 000`OiS ueЦ I SSellou lo有 leued Ч peJ!nboJ oЧ oouelleJ lぃ IЭ ol`s3押 00 pOu61(ョ epun eu上 ・ ons eJn‖ EI Ч e olloo角 ns Oq‖ eЧ s uqFo」 甲eD l olu ol SIel ott uo90d κUv.olul poJeluo」 o OpeuJ seM uolloesueJl slЧ l uoЧ ふ ° ・ D!Ч M uodn loel lo uolelumJdal leuoletu e si uol“ 」 ッoo,Ч ■ OpoЭ S・ ∩ Ч `ι Aq pesoduJI割 pue uo30esuol s:t101U16u,oluo Jo 6uttetu Jol alttnbolojd e si uo鯛 qじ 801!上 ;ι りoO,叩 10 peЭ eld seM 98)uolloes UO'S!Щ qns ・spunコ 1glep33 Ul 000'001$ 0Ufpmq qBluo3 pUB'Sluaujaaoy e^qeredoor3 'sluer6qng 's1ueto ot gtqect"ddv iluy(qqq Butpe6ag uoBB3$Ue3 Reque試 loF pす 。 .。 sぷ ATTACHMENtt A Region 10 Education Service Center lo: From: Organization Name proposal in collusion with any other Vendors and tre contents of this Proposal Vendorshali not prepare this by this organization nor by an employee or agent as to prices, lerms or conditions may not be communicated persons engaEed in Uris type of business activity prior of this oqanizatron io any other Vendor or lo any oher agentor offrcer signing tris Proposal is not and has to the official proposaloue oate. However, the authorized to control the conditions and/ or n,t been, for six months, direcuy or indirecrly concemed in any agreement person to popose or not purpose thereon' prices of services proposed, or fias not influenced any FULL LINE GR0CERY ITEMS WAREHOUSE' DIRECT I have rcad he complete Proposal RFP #2014-10 verify tlre accuracy of all informalion contained in the sHtp for member districis in Muiti Region co-op and Proposal. ふ 爵 £ BJc J鵬 幽 にご 協 肌 SuSAN MAMMARELLl ‖otary PubliC‐ Mソ m腱 町 ∞ m輛 面 岬 塾 :鵬 State 01 Fiorida ::譜 I「 15 ∬l後 ∬ 」可0 '鵬 cOmJete and retum Witt ProoosJ FULL LINfffiERY ITEMS WAREHOUSE, D ECI 'ShP RTT* 201+10 Page '19 of 29 ATTACHMENT B 朧 :∵ 織鳳 乱i指 盤織ギ t淵 b刷 i臨 1漑 訛 L器 脱 縞淵首 ヽ 9鷺 :緊 any Federaldepamento「 agency. °myぴ he statemmお d 需繁:h鵠 :』 鶴恩 乳 ∬ 出:酬鬼 i∬ ttS醐 淵1鶴 ∞ は SuCh is Proposal. :%朧 ∬渕 慧菫駄蠍 黎 柵 Co―Op may pursue any and a‖ ava‖ able remedies,including suspension and/ordebarment. ぶ ふ 肌 憚 鳳 紀 瀾 i捕猫鮮淵概勲贔卜 直 壻 塁 藤 機鱗 i榊聴 debarment PotentialVenCor Name. Tifle of Authorized Representative: 2_ゝ Maiing ttidresst Signature, Complete and retum FULL ttNEGROCERY「 EMSWAREHOUSEi DralShoRFP『 201410 PaEeZA of 29 ごと sァ untt sa11,Hl)and SeF責 博 LLC PH:281151400 AttACHMENT C FX:281‐ 2516507 CONFLiCT OF INTEREST QUES■ ONNAIRE FORM CIQ r vendor Or other person doing huslness wlth ioca` questionnaire is being filed in accordance with chapter 176 of the Local Code by a per:on doing business with the goYernmental enti\i- OFF'CE US■ ONLY )ate FiecivEd with the records administrator of the locil govemment not later than ihe 7th business day after the date the Person becomes aware of iacts that require tlie statement tb be filed. Sce Section 176.0o6, Loeel By law this questionnaire must be filed Govemment Code. person commits an offense if the pcrson violates Section 175.006, Local Gowrnrnent Code. An offunse under this section is a Class C misdemqanot' よ 5 Ct ".t ・ しし / this box if you a re filing an update to a naire wttn the● ppnttnatt fllln3 口℃ laW観 uires thtat vou■ le ar updated∞ mpleted quesjぃ al〈 la"rt鴨 n SeFtember l ofthe vearfOr wは ch an actM■ descrb2d in Sectlon 176.0061a),L∝ ttled the oriSirally date the day after business 7th code, is pending and not later *ran the [; rn i]Ct ,■,e nt recorn mendations 'rvith respct topxfinditures oi money to a local g,overnment oFficer of ttre governmental entity AND describe the affitiation or businesS reiatiorishlp' L s local 6overnment officers of the describe the affiliation or business AND frted is questionnaire snvernnrental entity for whj<d ttris AdOPted 170η 2005 FULL LiNE GROCERソ IIMSWAREHOUSE,Direct ttlp ttP#2Cr14J0 ?aEe21 ai?9 :LC unibd Sales and Sewi嚇 PH:281・ 251・ 6500 F(281・ 251807 OFINTEREST QUEST10NNAIRE Name of local govemnrcrrt lCOrnplete this le00n on″「 Thお secto口 ,item whom fil€r has affiliation or 昴ea― r toへ 町or c ISヤ E5), 5 hcbding subpaに A,aC&D′ / must be completed for eeChヴ 6Cer wth whom 。 the tter has am“ a● n Or other rdaOoい ship AttaCll addれ 'onalpags to ths ttm ctQaS necessary ノ ts likely to re{Eive taxable the lo.al government otficer n.med in this section from the filer of the questionnaire? 口 V・ I □ L ttnけ lyl.vla8 0F rthe ques藪 。 “ “ ol the CL・ e鮨 lGl govemrnent officer ざ 饉じqu蜀 ¨ 面 ニ ●no輸 "パ 3overRnent ofFlcer serV5基 mOに '口 Y“ recrive taxable income flom orat the thi5 seclion AND the taxable income is not from 面 衝 a∞ 7庶 cer or alrectoぅ 。 .therbuin6s m・ ヽ 市at he OrhddSan ome`hp of 10 percent or 口 0/′ “′ ′ ″ ´ 齢 tlon or b崚 ―S rdatlonshi, hcribe eacッ / / / 1● ′ ● ししこ ″ノ 5-t包 ヾ 4● ● "“ FULL LINE GRCCERY:TE■ lS IVAREHCuSE DFm Srわ RFP,即 1■ 10 =1/02′ Page 22 o129 。 。 ' Activities ,-"-?LJ*,E:xlx;rffi Disclosure of Lobbying l"rr,rJ[r, j.?;Lti"ilIT*ro3ru.s.c.i-]5.- Appiovcd c'' OME ・ ・はbn □ l鵠籍 『二 n a. C0lllrict I I b. grrn, c.post‐ ♂ward c. cooperarive agrcefirenl d. loan e. loan guarantee f. loan insurance 5. If Reportiog Entity in and Addrcss of 4. Namg and Address trf Ruporting Cnrirr: 1号 ConsressiodDistrict, i I know Congrc,sional Dist● ct,if k,oWn' Agency: Federal DePartment,r xo' a is;gdfawardee, r Only: Enter Name Prime: '{ ,/ ,1 ,1 ` adelfknow. □ ど □Prme 6. 3. Report'l'YPe: n a. initial filing LI 6. mz1g1ixt 3hxnoe, Fo( Material (:ha 2.Sutus oF Fcderal Actioni l. 'type of Federat Aclior: U. . t,! ,\-.' n: ncqrdt Program Name / Dcscription: CFDr\ ){umber, if aPPlicable: ,ir iion Number. il knolrB; E. lndividuals Pedorming servrces (inclurlirrg address if Ciffcrcnt tiom firsr name, Ml): ffil.r)bbvingEn(itY {if inriividual, last llarne, first name' Mi): .^t.**, ,f Pri..nr (check ail thar , : ? ,- ? a. rer.ai$er plenncd ? b. one-time lee ? c. commission 12. Form of Pay-mcnt (check all ? a. cash ? b. in-kind; ? d. contingsnt lbu ? c- deferred sPecirY-: n ? i. otherr sPecifY: ■r,iccs P。「∴FFCd。「 be ll::魔 IIIF:11 “ :鋪 鳳:ミ躙 10a)(lasl name' p口 → :(theck凛 ■饉■ applyf rcrual No )OF Sert・ icc,incLIふ perbrmed and Da sheer(s) (atrach Contin ion Sh● Ct(ヽ )Sr― LLL― A s g。 面 cer(S),e■ 1'Oyec(s),Or MCmbc〈 I;-LLL-;\, if S〕 necessary) attachCd: ?Ycs =N。 ed by articie 16.infon■ atioll rcqucsted thFOugh thiS fOrrn is authO,I′ a 31 lr.S.c.seCtiCn 1352.ThiS diSC10Sure oFiobby'■ 3 activitiCS iS bv upon which reriance was Praccd This *hen this ,runrr.,ion rvas made or enteted into' ― *;;i;;;;;;;;;;;i;;',,i.-i;;r iir"'i;"r 1352' This inforrnatir:n and will be availabtre scmianilually congress the to "u,i"* disclosure is required pr,,u,nt lo 31 U'S'C' *iti U. ,rrort..tl i"l ruLri. inspection..Anv よ ::│:ざ :L::轟 it:I:こ 島 ncrson :Tl9-llli: P. ldiド Ic・ Ittf:lliliボ * i」 and Ccnt rno10こ han S100,000 FoF e` ll:"t:;q"'ltiln l:ll贔 nu, p‖ :281‐ 251-3500 l'cdcrrrl tisrr OnlY: rAREHOl」 FULL LiNE GROCERYITEMS A・ SE.01面 Sn,RFP r 2111■ 10 Autburrizrd for I.ocal Re!roductioit Standartl Frcm - LLL Page 23 ol29 PROPOSAL FORM for CERTIFiCAT10N RECARDING TEXAS FAMiLY CODE by Sa鉾 !Acts,F晦 iぬuQ RS 1990:醐 the following andavL 悧l職sd“ l器淵闇鰤 置齋盤刷慧 l緞 l誌 詰 乱靡 Ю耗 轟葛Ⅲ 議も 編 二高品語 119ible lo Proposal or rece市 e a State contract. ADDRESS ■ 罵 ぃ PRINTED N Vや s S^ ずハL AND TITLE OF AUTHORiZED REPRESENTATiVE ダ′ ′ブ COFndett and return with PЮ 3 VVAREHOUSE,DOa Shい RF'j201410 DOSd P鴫 o25 of29 Food Wholesaler License lolesate lood manutactures and′ FimS that manufacture andわ r dislributt f00d fOr Sale to schools are lけ distributors"and must acquire he approplate ttCense with the Texas Depa」 bbn、 Food and Drug Safety,Manuhctured Foods D市 購:曇 翻 憑撼感品蓮 1盤 o「 hlenl o「 Health,Bureau● l 鵬 躙樵淵鮮財 精 leparmenl of Health(TDH): Texas DepOmentof H“ 識h Manufactured Food D市 islon l100 West 49JI Street Austin ttX 78756・ 3199 (388)963・ 7111 A∞ py of he F∞ d WhOlesaier License must be included With Proposal. ごm ヾ? cOpy d Food Whdesaler Ll∝ nse配 鮨d“ 面 血 PropOSま YeS Or間 二 疑 F三 一 一 一 一 一 Comdete and durn哺 衝 PЮ noSJ FULL LINEGROCERYITEMIミ REHOUI,Dttd飾 わRP μ2014‐ 10 Pη e26 of四 Clen Air andWabr Act pursuant to r. the Vendor, am in compliance with alt applicable standards, orders or regutaticns issued amended (33 Act, as ol the cban water ctean Air Act of 1g70, as Arnended (42 U.S.C. 1857(h)), section 508 Agency Regulation.40 CFR Part 15 as u.S.C. 136g), Executive Order 1173'Bg and EnvironmmtatProtection required under OMB Circular A-102, the violations to the grantor agency and to the United States Attachment 0, paragraph 14 (1) regarding reporting for the Enforcement' Environment Protection Agency Assistant Administrator Polental VendOr Title of Authorized Representative: 〕 20■ Ma面 ng Address: signaturei 薇FP#η 1410 Page 27 of西 CERTIFiCAT10N OF PROPOSAL SPECiFlCAT10NSRRMS&CONOIT10NS RFP″ 014o10 腱 朧融 暉 椰 “ 糠露驀脳撚彙 coMpANy clwi?で fir::ts Nnur: flornn 44,; address: 餞 r61c ptt h輔 , lT-nc- :た Sね ね ‐ 力ttt,■ ― , 乙多 「 W― … ・ … … … L5 9t´ … RESIDENT VENDOR CERTIFICAIION informatbn must be provided. Failure to comoleie may rn order for proposar to be considered, the fo[owing result in reJection of the oroposal: As defined by Texas a vendor whose principal clace of rioil*ari 002, a "nonresident vendor' frleans parent company or majonty owner has its +rtrose ultimate business is not in Texas, but excludes a coniractor my cgmpany is a'Tesident vendor': prirripri place of business in Texas, I certify that Date: Signature lf you q ・ 訂計 僣赫 蕊 vendor,' vou ry st.!T:,l uali! as a "nonresident 'ま lit^l1P:Y:t:Hl:l' plndpd口 a∝ dbuSnesb bCatedl i3品 L`高 恐 1高 品爵 σ ″ 04 Company Name Cty °ldに 01緞ぽ薦∬鮒ξ鱚 oompambb con戯_“ Reslde∝ e (B) Addre“ 撚f津 :穏t∬ 警[朧 1 譜躍憾h慇 聖滉 he plndpJが ・ means he sね 撻 h Whに tta鯰 ace of bujness t 10CaOd ge?2≧ % m am話轟 高ね 試 瀧‖ しい Cotrpany 赫 面 画 面 面 IAREHOUSE.馴 m Shlp RFP#富 嘉赦 Name Page 28 o129 "0 PROPO SAL ACKNOWLEDGI{ENT FULL LINE GROCERY ITEMSWAREHOUSE, DIRECT SHIP lRrPf T0: #2014"101 Education Service Center Region 10 i, or we, the duly authorized undensigned, having carefully red the lnstructions to Offerors, General Conditions, Notice to Cfferors, Contract Specifications, Responsibilities of Offerors, and Proposal Forms, do hereby agree to enter into a contract wrth Region 10 by tendering tu's offer to perform the work reouired per specifications and/oi provide the product(s) specified in this solicitation. l, or we, willdeliverthe product(s) the found in this proposal documeni for the prices indicated. l, 0r we, also certify to the accuracy of Water Acti certifications requrred (including, but not limited to, Felony Conviction Notic,e or Clean Air and which accompany this offer. l, or we, will follow all applicable state or federal laws' or The prices in this offer have been determined independently, without consuftation, mrnmunication, prices, with any other agreement tor ihe purpose of restricting competition, as to any matter related to such have not been a party to any orhror or with any competitor. l, or we. are aulhorized to submil this offer and offer at a fixed price or to coilusion am6ng offer/offerors in restraint of freedom of competition by agreement to consultant as to quantity, quality, or refrain from ofriring; or rvith any Region 10 employee, Board Drector, or any authcrized pnce in the prosjmtive contrmt, or in any terms of the prospective conbact except in offer/offerors between or actions discussion(s) with Region 10's Business perscnnel; or in any discussions things of other or rnoney of exchange and any negion 10 employee. Board Diredor or consultant conceming value for soecial consideration in the award of this contraci' Date. Firrn's Address 0こ ら丁 ´ ち と 2'´ Namefr「 Ile: Phone #: r"^*, tss-444- t/7{'/ss or Fed lD#: PROPOSAL ENVELOPES SHOULD BE PLAINLY MARKED: IRF諄 燿 014・ 101 MJ轟・Regbnd C● RequestfOrPropllal'稚 “ 鍵謂 I嵩調 鳳 乳 usE,回 旺 CT SHP' 111::1:lil:IchiefFinancialCttncer 400 East Spring Va‖ ey Rd, RIchardson,Texas 75081 DUE:Thursday,May 29:2014 at 4:30 pm Comdeわ and FULi_日 NE GROCERYITEMSヽ ヽ証 retum with口 ЮoOSd HOuSE,Diゐ 歓 Ship RFP#2014‐ 10 Ptte 29 of29
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