HomeMy WebLinkAbout2015-230 Contract - Northwest CDL Testing
Contract for GOODS AND SERVICES Small Procurement Less than $5,000
CITY OF INDEPENDENT CONTRACTOR:
-45 H L A N D CONTACT:
20 East Main Street
ADDRESS:
C> X `lr!~ J
Ashland, Oregon 97520 ~~ci'
7~
Telephone: 541/488-6002
Fax: 541/488-5311 TELEPHONEd l' FAX:
BEGINNING DATE: COMPLETION DATE: 7~_- ,
COMPENSATION:
GOODS AND SERVICES TO BE PROVIDED:
In the event of conflicts or discrepancies among Contract Documents, this standard form of the City of Ashland Contract will be primary and
take precedence, and any exhibits or ancillary contracts or agreements having redundant or contrary provisions will be subordinate to and
interpreted in a manner that will not conflict with this standard form City of Ashland Contract.
NOW THEREFORE, pursuant to AMC 2.50.090 and after consideration of the mutual covenants contained herein the CITY AND CONTRACTOR
AGREE as follows:
1. All Costs by Contractor: Contractor shall, provide all goods as specified above and shall at its own risk and expense, perform any work
described above and, unless otherwise specked, furnish all labor, equipment and materials required for the proper performance of such work.
2. Qualified Work: Contractor has represented, and by entering into this contract now represents, that any personnel assigned to the work required
under this contract are fully qualified to perform the work to which they will be assigned in a skilled and worker-like manner and, if required to be
registered, licensed or bonded by the State of Oregon, are so registered, licensed and bonded. Contractor must also maintain a current City
business license.
3. Ownership of Production: All documents, materials or items produced by Contractor pursuant to this contract shall be the property of City.
4. Statutory Requirements: ORS 279B.220, 2798.225, 279B.230, 279B.235, ORS Chapter 244 and ORS 670.600 are made part of this contract.
5. Indemnification: Contractor agrees to defend, indemnify and save City, its officers, employees and agents harmless from those losses, expenses,
or other damages resulting from injury to any person or damage to property arising out of or incident to the negligent performance of this contract
by Contractor its employees, or agents. Contractor shall not be held responsible for any losses, expenses, or other damages, directly, solely, and
proximately caused by the negligence of City.
6. Termination: City's Convenience. This contract may be terminated at any time by the City.
7. Independent Contractor Status: Contractor is an independent Contractor and not an employee of the City. Contractor shall have the complete
responsibility for the performance of this contract.
8. Non-discrimination Certification: The undersigned certifies that the undersigned Contractor has not discriminated against minority, women or
emerging small businesses enterprises in obtaining any required subcontracts. Contractor further certifies that it shall not discriminate in the award
of such subcontracts, if any.
9. Asbestos Abatement License: If required under ORS 468A.710, Contractor or Subcontractor shall possess an asbestos abatement license.
10. Assignment and Subcontracts: Contractor shall not assign this contract or subcontract any portion of the work.
11. Use of Recyclable Products: Contractor shall use recyclable products to the maximum extent economically feasible in the performance of the
contract work set forth in this document.
12. Default. The Contractor shall be in default of this agreement if Contractor commits any material breach or default of any covenant, warranty,
certification, or obligation it owes under the Contract.
13. Insurance. Contractor shall at its own expense provide the following insurance:
a. a. Worker's Compensation insurance in compliance with ORS 656.017, which requires subject employers to provide Oregon workers'
compensation coverage for all their subject workers. Worker's compensation insurance is required if work is performed by employees,
subcontractors, or volunteers.
BY INITIALING THIS SENTENCE, CONTRACTOR CERTIFIES UNDER PENALTY OF LAW THAT THE WORK REQUIRED BY THIS
CONTRACT SHALL BE PERFORMED SOLELY BY THE UNDERSIGNED:.
b. General Liability insurance with a combined single limit, or the equivalent, of not less than $1,000,000 for each occurrence for Bodily Injury
and Property Damage.
C. Automobile Liability insurance with a combined single limit, or the equivalent, of not less than $1,000,000 for each accident for Bodily
Injury and Property Damage, including coverage for owned, hired or non-owned vehicles, as applicable.
14. Governing Law; Jurisdiction; Venue: This contract shall be governed and construed in accordance with the laws of the State of Oregon
15. THIS CONTRACT AND ATTACHED EXHIBITS CONSTITUTE THE ENTIRE AGREEMENT BETWEEN THE PARTIES. NO WAIVER, CONSENT,
MODIFICATION OR CHANGE OF TERMS OF THIS CONTRACT SHALL BIND EITHER PARTY UNLESS IN WRITING AND SIGNED BY BOTH
PARTIES.
Certification. Contractor shall sign the certification attached hereto as Exhibit A and herein incorporated b reference.
Contractor: City of Ashland:
By, .E -e-, " By
ignature Departm ntyea
1 ~ A i1A
Print Name _ Print Name
Title Oate
W-9 One copy of a W-9 is s to be submitted with the signed contract. Purchase Order NO. E jam"
Revised 10-28-14 Page 1 of 2
EXHIBIT A
CERTIFICATIONS/REPRESENTATIONS: Contractor, under penalty of perjury, certifies that (a) the number shown on
the attached W-9 form is its correct taxpayer ID (or is waiting for the number to be issued to it and (b) Contractor is not
subject to backup withholding because (i) it is exempt from backup withholding or (ii) it has not been notified by the
Internal Revenue Service (IRS) that it is subject to backup withholding as a result of a failure to report all interest or
dividends, or (iii) the IRS has notified it that it is no longer subject to backup withholding. Contractor further represents
and warrants to City that (a) it has the power and authority to enter into and perform the work, (b) the Contract, when
executed and delivered, shall be a valid and binding obligation of Contractor enforceable in accordance with its terms, (c)
the work under the Contract shall be performed in accordance with the highest professional standards, and (d) Contractor
is qualified, professionally competent and duly licensed to perform the work. Contractor also certifies under penalty of
perjury that its business is not in violation of any Oregon tax laws, and it is a corporation authorized to act on behalf of the
entity designated above and authorized to do business in Oregon or is an independent Contractor as defined in the
contract documents, and has checked four or more of the following criteria:
r
~ (1) I carry out the labor or services at a location separate from my residence or is in a specific portion of my
residence, set aside as the location of the business.
(2) Commercial advertising or business cards or a trade association membership are purchased for the
/ business.
V (3) Telephone listing is used for the business separate from the personal residence listing.
(4) Labor or services are performed only pursuant to written contracts.
(5) Labor or services are performed for two or more different persons within a period of one year.
(6) 1 assume financial responsibility for defective workmanship or for service not provided as evidenced by
the ownership of performance bonds, warranties, errors and omission insurance or liability insurance relating
to the labor or services to be provided.
Contractor (Date)
Revised 10-28-14 Page 2 of 2
CDL CERTIFICATE OF
f 3-54
0E5
OREGONO TEST COMPLETION
pp NP AVE NE. SALEM OREGON p)ptt
INSTRUCTIONS: 1. Give drive test according to OAR 735-060-0120.
2. Complete this form for all drivers who pass or fail the test. Print or type.
3. If passes, place the white copy in an envelope and seal. Sign your name on the seal.
4. If passes or fails, give the pink copy to the driver and keep the yellow copy for your files.
5. INSTRUCT THE DRIVER TO TAKE THE SEALED ENVELOPE TO A DMV OFFICE.
T APPLICANT INFORMATION
APPLICANT NAME (PRINT LAST, FIRST MIDDLE) _
DATE OF BIRTH (M-D-Y) /4 r OREGON DRIVER LICENSE NUMBER.
V TYPE • VEHICLE USED FOR TEST V
QCLASS A ❑'CLASS B OCLASS C
• DID THE POWER UNIT USED FOR THE TEST HAVE: JJ A FULL AIRBRAKE SYSTEM? OAIR-OVER-HYDRAULIC BRAKES?
• WAS THE TEST VEHICLE A: OPASSENGER-CARRYING VEHICLE? OSCHOOL BUS AS DEFINED BY ORS 801.460?
• DID THE TEST VEHICLE HAVE: OAN AUTOMATIC TRANSMISSION?
• IF CLASS A, DID THE TEST VEHICLE: OUSE A FIFTH WHEEL COUPLING SYSTEM?
EXAMINER INFORMATION AND CERTIFICATION v
DATE OF TEST r _ NAME OF THIRD-PARTY;TESTER (PRINTED)
NAME OF THIRD-PARTY EXAMINER (PRINTED) ,
• DOES THE EXAMINER HAVE AN ENDORSEMENT FOR: OA PASSENGER VEHICLE? OA SCHOOL BUS?
• DOES THE EXAMINER HAVE A RESTRICTION FOR: ❑AIR BRAKE OR; OPARTIAL AIR BRAKE? ❑ FAILED
NOTE: THE EXAMINER MUST BE LICENSED TO OPERATE ANY
VEHICLE IN WHICH THEY TEST. OFIFTH WHEEL? OAUTOMATIC TRANSMISSION?
I certify that the applicant named above passed a CDL skills test, given and scored by me in accordance with OAR 735-060-0120, in the
type of vehicle indicated. I further certify that the statements on this form are true. I understand that it is a crime under ORS 162.085 to
certify the truth of a statement when I know the statement is not true. Such a crime is punishable by a jail sentence of up to six months, and
fine of up to $2,500, or both. By OAR 735-060-0115(1) and OAR 735-060-0105(3)(f), an examiner who assists a CDL applicant to
fraudulently obtain driving privileges is subject to permanent revocation.
DATE /
V TEST FEES PAID
CDL Test $ - -
Travel Surcharge $
Vehicle Rental $
Other (Specify): $
TOTAL: $ l
It is a violation of ORS 807.530 to fraudulently obtain CDL driving privileges by providing fraudulent identity documents or offer a bribe to
the CDL Third Party Examiner. Such acts may result in criminal prosecution, suspension of driving privileges, or both. I understand that
DMV has the authority under ORS 807.340 to require a retest with DMV personnel. If I fail to comply with a retest, DMV will cancel my
commercial driving privileges.
SIGNATURE OF APPLICANT DATE/ _
REPORT SUSPECTED FRAUDULENT TESTING TO DMV (503) 945-8916
• OF VEHICLE CLASSES •-TESTING V
CLASS A COMMERCIAL VEHICLE (any combination of vehicles with a Gross Combination Weight Rating (GCWR) of 26,001 or more
pounds provided the GVWR of the vehicle(s) being towed is in excess of 10,000 pounds).
CLASS B COMMERCIAL VEHICLE (single vehicle with GVWR of more than 26,000 pounds).
CLASS C COMMERCIAL VEHICLE (single vehicle with GVWR of 26,000 pounds or less carrying 16 or more passengers or hazardous
materials).
111119~1 Mill
APPLICANT
4EM CDL CERTIFICATE OF
DEPARTMENTOFTAANSPORfATION OO~ 1»
F~
O05 LAANO MOTOR VEHICLE SERVICES TEST COMPLETION A.^'
1P05IANA AVE NE. SALEM A1 OREGON YT]14
`
INSTRUC (IONS: 1. Give drive test according to OAR 735-060-0120.
2. Complete this form for all drivers who pass or fail the test. Print or type.
3. If passes, place the white copy in an envelope and seal. Sign your name on the seal.
4. If passes or fails, give the pink copy to the driver and keep the yellow copy for your files.
5. INSTRUCT THE DRIVER TO TAKE THE SEALED ENVELOPE TO A DMV OFFICE.
APPLICANT INFORMATION
APPLICANT NAME (PRINT LAST, FIRS-T MIDDLE)
DATE OF BIRTH (M-D-Y) OREGON DRIVER LICENSE NUMBER
TYPE OF VEHICLE USED FOR TEST V
f'- (CLASS A ❑CLASS B ❑CLASS C
1-1
• DID THE POWER UNIT USED FOR THE TEST HAVE: 0A FULL AIRBRAKE SYSTEM? ❑AIR-OVER-HYDRAULIC BRAKES?
• WAS THE TEST VEHICLE A: ❑PASSENGER-CARRYING VEHICLE? ❑SCHOOL BUS AS DEFINED BY ORS 801.460?
• DID THE TEST VEHICLE HAVE: ❑AN AUTOMATIC TRANSMISSION?
• IF CLASS A, DID THE TEST VEHICLE: ❑USE A FIFTH WHEEL COUPLING SYSTEM?
V EXAMINER INFORMATION AND CERTIFICATION T
DATE OF TEST NAME,.OFTHIRD-PARTY TESTER (PRINTED) '
NAME OF THIRD-PARTY EXAMINER (PRINTED)
• DOES THE EXAMINER HAVE AN ENDORSEMENT FOR: 177A PASSENGER VEHICLE? ❑A SCHOOL BUS?
• DOES THE EXAMINER HAVE A RESTRICTION FOR: ❑AIR BRAKE OR; ❑PARTIAL AIR BRAKE? ❑ FAILED
NOTE: THE EXAMINER MUST BE LICENSED TO OPERATE ANY
VEHICLE IN WHICH THEY TEST. ❑FIFTH WHEEL? ❑AUTOMATIC TRANSMISSION?
I certify that the applicant named above passed a CDL skills test, given and scored by me in accordance with OAR 735-060-0120, in the
type of vehicle indicated. I further certify that the statements on this form are true. I understand that it is a crime under ORS 162.085 to
certify the truth of a statement when I know the statement is not true. Such a crime is punishable by a jail sentence of up to six months, and
fine of up to $2,500, or both. By OAR 735-060-0115(1) and OAR 735-060-0105(3)(f), an examiner who assists a CDL applicant to
fraudulently obtain driving privileges is subject to permanent revocation.
DATE
V JEST FEES PAID V
CDL Test
Travel Surcharge $
Vehicle Rental $
Other (Specify): $
TOTAL: $ f`
It is a violation of ORS 807.530 to fraudulently obtain CDL driving privileges by providing fraudulent identity documents or offer a bribe to
the CDL Third Party Examiner. Such acts may result in criminal prosecution, suspension of driving privileges, or both. I understand that
DMV has the authority under,ORS 807.340 to require a retest with DMV personnel. If I fail to comply with a retest, DMV will cancel my
commercial driving privileges.'
SIGNATURE-OF "APPLICANT / DATE _
REPORT SUSPECTED FRAUDULENT TESTING TO DMV (503) 945-8916
• • A •
CLASS .A COMMERCIAL VEHICLE (any combination of vehicles with a Gross Combination Weight Rating (GCWR) of 26,001 or more
pounds provided the GVWR of the vehicle(s) being towed is in excess of 10,000 pounds).
CLASS B COMMERCIAL VEHICLE (single vehicle with GVWR of more than 26,000 pounds).
CLASS C COMMERCIAL VEHICLE (single vehicle with GVWR of 26,000 pounds or less carrying 16 or more passengers or hazardous
materials).
APPLICANT
10,709 CDL CERTIFICATE OF
DE PAMENIOFTRANSPORTATON
DRIVER AND MOTOR VEHICLE SERVICES
TEST COMPLETION
1005 IANA AVE NE. SALEM OREGON 01]14
INSTRUCTIONS: 1. Give drive test according to OAR 735-060-0120.
2. Complete this form for all drivers who pass or fail the test. Print or type.
3. If passes, place the white copy in an envelope and seal. Sign your name on the seal.
4. If passes or fails, give the pink copy to the driver and keep the yellow copy for your files.
5. INSTRUCT THE DRIVER TO TAKE THE SEALED ENVELOPE TO A DMV OFFICE.
APPLICANT INFORMATION V
APPLICANT NAME (PRINT LAST, FIRST, MIDDLE)
~ r f
DATE OF BIRTH (M-D-Y)' OREGON DRIVER LICENSE NUMBER
TYPE OF VEHICLE USED FOR TEST V
= CLASS A CLASS B CLASS C
AIR-OVER HYDRAULIC BRAKES?
• DID THE POWER UNIT USED FOR THE TEST HAVE: FF-,/]A FULL AIRBRAKE SYSTEM?
F
• WAS THE TEST VEHICLE A: PASSENGER-CARRYING VEHICLE? SCHOOL BUS AS DEFINED BY ORS 801.460?
• DID THE TEST VEHICLE HAVE: DAN AUTOMATIC TRANSMISSION?
• IF CLASS A, DID THE TEST VEHICLE: ❑USE A FIFTH WHEEL COUPLING SYSTEM?
EXAMINER INFORMATION AND CERTIFICATION v
DATE OF TEST NAME OF THIRD-PARTY TESTER (PRINTED)
NAME OF THIRD-PARTY EXAMINER (PRINTED) '
I
• DOES THE EXAMINER HAVE AN ENDORSEMENT FOR: EA PASSENGER VEHICLE? F_]A SCHOOL BUS?
`r
• DOES THE EXAMINER HAVE A RESTRICTION FOR: FIAIR BRAKE OR; PARTIAL AIR BRAKE? (FAILED
NOTE: THE EXAMINER MUST BE LICENSED TO OPERATE ANY
VEHICLE IN WHICH THEY TEST. ; ❑FIFTH WHEEL? AUTOMATIC TRANSMISSION?a
I certify that the applicant named above passed a CDL skills test, given and scored by me in accordance with OAR 735-060-0120, in the
type of vehicle indicated. I further certify that the statements on this form are true. I understand that it is a crime under ORS 162.085 to
certify the truth of a statement when I know the statement is not true. Such a crime is punishable by a jail sentence of up to six months, and
fine of up to $2,500, or both. By OAR 735-060-0115(1) and OAR 735-060-0105(3)(0, an examiner who assists a CDL applicant to
fraudulently obtain driving privileges is subject to permanent revocation.
DATE
V TEST FEES PAID V
CDL Test $
Travel Surcharge $
Vehicle Rental $
Other (Specify): $
TOTAL: $
It is a violation of ORS 807.530 to fraudulently obtain CDL driving privileges by providing fraudulent identity documents or offer a bribe to
the CDL Third Party Examiner. Such acts may result in criminal prosecution, suspension of driving privileges, or both. I understand that
DMV has the authority under ORS 807.340 to require a retest with DMV personnel. If I fail to comply with a retest, DMV will cancel my
commercial driving privileges.
SIGNATURE OFAPPLICANT,~ _ DATE_
REPORT SUSPECTED FRAUDULENT TESTING TO DMV (503) 945-8916
• OF VEHICLE CLASSES FOR TESTING V
CLASS A COMMERCIAL VEHICLE (any combination of vehicles with a Gross Combination Weight Rating (GCWR) of 26,001 or more
pounds provided the GVWR of the vehicle(s) being towed is in excess of 10,000 pounds).
CLASS B COMMERCIAL VEHICLE (single vehicle with GVWR of more than 26,000 pounds).
CLASS C COMMERCIAL VEHICLE (single vehicle with GVWR of 26,000 pounds or less carrying 16 or more passengers or hazardous
materials).
APPLICANT
a 01 m N CDL CERTIFICATE OF
O ER NO
AATMENTOFTR~NS~RTATION TEST COMPLETION ° ° -
ANOMOTOR VEHICLE SERVICES
100S05 LA NA AVE NE, SALEM OREGON M14 "
INSTRUCTIONS: 1. Give drive test according to OAR 735-060-0120.
2. Complete this form for all drivers who pass or fail the test. Print or type.
3. If passes, place the white copy in an envelope and seal. Sign your name on the seal.
4. If passes or fails, give the pink copy to the driver and keep the yellow copy for your files.
5. INSTRUCT THE DRIVER TO TAKE THE SEALED ENVELOPE TO A DMV OFFICE.
APPLICANT INFORMATION
AP_P_LICANT NAME (PRINT LAST, FIRST, MIDDLE) r<
DATE OF BIRTH (M-D-Y)' OREGON DRIVER LICENSE NUMBEF_
V TYPE • FOR TEST
F-1 CLASS A J7] CLASS B ❑CLASS C
• DID THE POWER UNIT USED FOR THE TEST HAVE: .OA FULL AIRBRAKE SYSTEM? OAIR-OVER-HYDRAULIC BRAKES?
• WAS THE TEST VEHICLE A: OPASSENGER-CARRYING VEHICLE? [-]SCHOOL BUS AS DEFINED BY ORS 801.460?
• DID THE TEST VEHICLE HAVE: OAN AUTOMATIC TRANSMISSION?
• IF CLASS A, DID THE TEST VEHICLE: OUSE A FIFTH WHEEL COUPLING SYSTEM?
F11 J11 III, I A.-A JIF.A • •
DATE OF TEST NAME OF THIRD-PARTY TESTER (PRINTED)., i ,
NAME-OF THIRD-PARTY EXAMINER (PRINTED);
• DOES THE EXAMINER HAVE AN ENDORSEMENT FOR: A PASSENGER VEHICLE? OA SCHOOL BUS?
• DOES THE EXAMINER HAVE A RESTRICTION FOR: ❑AIR BRAKE OR; OPARTIAL AIR BRAKE? ❑ FAILED
NOTE: THE EXAMINER MUST BE LICENSED TO OPERATE ANY
VEHICLE IN WHICH THEY TEST. OFIFTH WHEEL? OAUTOMATIC TRANSMISSION?
I certify that the applicant named above passed a CDL skills test, given and scored by me in accordance with OAR 735-060-0120, in the
type of vehicle indicated. I further certify that the statements on this form are true. I understand that it is a crime under ORS 162.085 to
certify the truth of a statement when I know the statement is not true. Such a crime is punishable by a jail sentence of up to six months, and
fine of up to $2,500, or both. By OAR 735-060-0115(1) and OAR 735-060-0105(3)(f), an examiner who assists a CDL applicant to
fraudulently obtain driving privileges is subject to permanent revocation.
DATE
_ `
V TEST FEES PAID V
CDL Test $
Travel Surcharge $
Vehicle Rental $
Other (Specify): $
TOTAL: $ -
It is a violation of ORS 807.530 to fraudulently obtain CDL driving privileges by providing fraudulent identity documents or offer a bribe to
the CDL Third Party Examiner. Such acts may result in criminal prosecution, suspension of driving privileges, or both. I understand that
DMV has the authority under ORS 807.340 to require a retest with DMV personnel. If I fail to comply with a retest, DMV will cancel my
commercial driving privileges.
SIGNATURE OF APPLICANT DATE
REPORT SUSPECTED FRAUDULENT TESTING TO DMV (503) 945-8916
• OF EHICLE CLASSES FOR TESTING V
CLASS A COMMERCIAL VEHICLE (any combination of vehicles with a Gross Combination Weight Rating (GCWR) of 26,001 or more
pounds provided the GVWR of the vehicle(s) being towed is in excess of 10,000 pounds).
CLASS B COMMERCIAL VEHICLE (single vehicle with GVWR of more than 26,000 pounds).
CLASS C COMMERCIAL VEHICLE (single vehicle with GVWR of 26,000 pounds or less carrying 16 or more passengers or hazardous
materials).
E~Millll
APPLICANT
Page 1 / 1
CITY OF
DATE PO NUMBER
ASHLAND
,l 20 E MAIN ST. 8/24/2015 13087
ASHLAND, OR 97520
(541) 488-5300
VENDOR: 019705 SHIP TO: Ashland Street Department
NORTHWEST CDL TESTING (541) 488-5313
PO BOX 1818 90 N. MOUNTAIN
ROSEBURG, OR 97470 ASHLAND, OR 97520
FOB Point: Req. No.:
Terms: Net Dept.:
Req. Del. Date: Contact: John Peterson
Special Inst: Confirming? No
Quantity Unit Description Unit Price Ext. Price
CDL Testing for (4) Emplovees 600.00
4 (c) $150.00 Each
SUBTOTAL 600.00
BILL TO: Account Payable TAX 0.00
20 EAST MAIN ST FREIGHT 0.00
541-552-2010 TOTAL 600.00
ASHLAND, OR 97520
Account Number Project Number Amount Account Number Project Number Amount
E 260.08.12.00.60650 600.00
Auto zed Signature VENDOR COPY
FORM #3' 'VT Y O F
,f _ ASI~LAND
REQUISITION , + ofregtresfi~ , 08/17/2015
Required date for delivery:
Vendor Name Nnrthwact C N Tacting (I ana'c Tactic
Address, City, State, Zip P.O. Box 1818
Contact Name & Telephone Number Roseburg, OR. 97470
Fax Number
SOURCING METHOD
❑ Exempt from Competitive Bidding ❑ Emergency
❑ Reason for exemption: ❑ Invitation to Bid (Copies on file) ❑ Form #13, Written findings and Authorization
❑ AMC 2.50 Date approved by Council: ❑ Written quote or proposal attached
❑ Written quote or proposal attached
❑ Small Procurement Cooperative Procurement
Less than $5,000 ❑ Request for Proposal (Copies on file) ❑ State of Oregon
X Direct Award Date approved by Council: Contract #
❑ VerballWritten quote(s) or proposal(s) ❑ State of Washington
Intermediate Procurement ❑ Sole Source Contract #
GOODS & SERVICES ❑ Applicable Form (#5,6, 7 or 8) ❑ Other government agency contract
$5,000 to $100,000 ❑ Written quote or proposal attached Agency
❑ (3) Written quotes and solicitation attached ❑ Form #4, Personal Services $5K to $75K Contract #
PERSONAL SERVICES ❑ Special Procurement Intergovernmental Agreement
$5,000 to $75.000 ❑ Form #9, Request for Approval ❑ Agency
❑ Less than $35,000, by direct appointment ❑ Written quote or proposal attached Date original contract approved by Council:
❑ (3) Written proposals/written solicitation Date approved by Council: (Date)
❑ Form #4, Personal Services $5K to $75K Valid until: Date
Description of SERVICES Total Cost
CDL Testing for 4 Employees $600.00
Item # Quantity Unit Description of MATERIALS Unit Price Total Cost
TOTAL COST
X Per attached quotelproposal $
Project Number _ _ _ _ _ _ - _ _ _ Account Number 260 - 08 -12- 00 - 606500
Account Number Account Number
'Expenditure must be charged to the appropriate account numbers for the financials to accurately reflect the actual expenditures.
IT Director in collabor ' n with epartment to approve all hardware and software purchases:
IT Director Date Support -Yes/ No
By signing this req is' ion f rm, I erti 1ha iae City's public contracting requirements have been satisfied.
Employee: Department Head: 42
(Equal to or greaterthan $5,000)
Department ManagerlSupervisor: City Administrator:
(Equal to or greater than $25,000)
Funds appropriated for current fiscal year YES / NO
Finance Director- (Equal to or greater than $5,000) Date
Comments:
Form #3 - Requisition
f, PRIHTEO WffH
Northwest CDL Testin 51 "2
SANDRA UTLEY
THIRD PARTY TESTER C2~ /
P.O. BOX 1818
ROSEBURG, OR 97470
(541) 580-3907
N° 2196
Customer's 20
Order No. Date
Name /00
Address
Phone:
SOLD BY CASH C.O.D. CHARGE ON ACCT. MDSE. RETD. PAID OUT LAYAWAY
I
I
l
/ SD
I
I
tee
I
I All claims and returned goods MUST be accompanied by this bill.
Received
GSCC-652-2 _ p
PRINTED IN U.S.A. j....:~. VY&V j