WORK AUTHORIZATION Master Agreement for Services and Maintenance

Transcription

1 DeKalb County Board of Education ( Owner ) 1780 Montreal Road Tucker, Georgia Phone Fax The following number must appear on all related correspondence and invoices: WORK AUTHORIZATION Master Agreement for Services and Maintenance W.A. NUMBER: Contractor: [Name] [Company] [Street Address] [City, ST ZIP Code] (the Service Contractor ) PROJECT/SCHOOL: [Name] [Company] [Street Address] [City, ST ZIP Code] (the Project ) ADA (504) LSPR Maintenance Emergency Other W.A. DATE REQUISITIONER Commencement Date Completion Date Payment & Performance Bond YES NO The Service Contractor shall provide the Owner the following Services with respect to the Project: As part of its Services, the Service Contractor shall produce for and/or deliver to the Owner the following tangible products, goods or deliverables (examples: reports, plans, financial estimates, parts, equipment, materials, etc.) The Services (describe the Project and the scope of work for this Work Authorization): 1

2 (TOTAL OF ALL WORK AUTHORIZATIONS SHALL NOT EXCEED THE MAXIMUM AMOUNT PAYABLE UNDER THE CONTRACT AS SET FORTH IN ARTICLE 4, SECTION 4.1) Contract Price: The Contract Price for this Work Authorization is DOLLARS ($ ). This Work Authorization incorporates by reference the MASTER AGREEMENT FOR SERVICES UNDER WORK AUTHORIZATION dated, 20 (including all Exhibits thereto); Attachment 1 hereto, Immigration and Security Form and accompanying affidavits; Attachment 2 the Service Contractor s Insurance Certificate(s); and, the following (if any): Attachment 3 the Service Contractor s Quotation/Proposal (all of which are collectively referred to as the Contract Documents for the Project). IN WITNESS WHEREOF, the Owner and the Service Contractor, intending to be legally bound and each acting through persons duly authorized, have placed their signatures on duplicate original copies of this Contract. DeKalb County Board of Education Service Contractor Crawford Lewis, PHD. Superintendent Legal Name of Contractor Patricia A. Pope By Corporate Seal Chief Operations Officer Date of Execution Title If this Work Authorization is $50,000 or more. The following additional signature is required: Thomas E. Bowen Board Chair Address Date of Execution 2

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4 ATTACHMENT 1 (REQUIRED TO BE COMPLETED BY ALL CONTRACTORS AND SUBCONTRACTORS FOR EACH WORK AUTHORIZATION) IMMIGRATION AND SECURITY FORM A. In order to insure compliance with the Immigration Reform and Control Act of 1986 (IRCA), Pub.L and the Georgia Security and Immigration Compliance Act O.C.G.A et. seq., Contractor and all Subcontractors must initial one of the sections below: Contractor has 500 or more employees and Contractor warrants that Contractor has complied with the Immigration Reform and Control Act of 1986 (IRCA) Pub.L and the Georgia Security and Immigration Compliance Act by registering at and verifying information of all new employees; and by executing any affidavits required by the rules and regulations issued by the Georgia Department of Labor set forth at Rule et. seq. Contractor has employees and Contractor warrants that no later than July 1, 2008, Contractor will register at to verify information of all new employees in order to comply with the Immigration Reform and Control Act of 1986 (IRCA) Pub.L and the Georgia Security and Immigration Compliance Act; and by executing any affidavits required by the rules and regulations issued by the Georgia Department of Labor set forth at Rule et. seq. Contractor has 99 or fewer employees and Contractor warrants that no later than July 1, 2009, Contractor will register at to verify information of all new employees in order to comply with the Immigration Reform and Control Act of 1986 (IRCA), Pub.L and the Georgia Security and Immigration Compliance Act; and by executing any affidavits required by the rules and regulations issued by the Georgia Department of Labor set forth at Rule et. seq. B. Contractor warrants that Contractor has included a similar provision in all written agreements with any subcontractors engaged to perform services under its Contract(s) with the DeKalb County Board of Education. Signature Title Firm Name: Street/Mailing Address: City, State, Zip Code: Telephone Number: Address: 4

5 CONTRACTOR AFFIDAVIT By executing the affidavit, the undersigned contractor verifies its compliance with O.C.G.A , stating affirmatively that the individual, firm or corporation which is engaged in the physical performance of services under a contract with (name of contractor) on behalf of (name of public employer) has registered with and is participating in a federal work authorization program* [any of the electronic verification of work authorization programs operated by the United States Department of Homeland Security or any equivalent federal work authorization program operated by the United States Department of Homeland Security to verify information of newly hired employees, pursuant to the Immigration Reform and Control Act of 1986 (IRCA), P.L ], in accordance with the applicability provisions and deadlines established in O.C.G.A EEV / Basic Pilot Program* User Identification Number BY: Authorized Officer of Agent Date (Contractor Name) Title of Authorized Officer or Agent of Contractor Printed Name of Authorized Officer or Agent SUBSCRIBED AND SWORN BEFORE ME ON THIS THE DAY OF, 20 Notary Public My Commission Expires: * As of the effective date of O.C.G.A , the applicable federal work authorization program is the EEV / Basic Pilot Program operated by the U.S. Citizenship and Immigration Services Bureau of the U.S. Department of Homeland Security, in conjunction with the Social Security Administration (SSA). 5

6 SUBCONTRACTOR AFFIDAVIT By executing the affidavit, the undersigned subcontractor verifies its compliance with O.C.G.A , stating affirmatively that the individual, firm or corporation which is engaged in the physical performance of services under a contract with (name of contractor) on behalf of (name of public employer) has registered with and is participating in a federal work authorization program* [any of the electronic verification of work authorization programs operated by the United States Department of Homeland Security or any equivalent federal work authorization program operated by the United States Department of Homeland Security to verify information of newly hired employees, pursuant to the Immigration Reform and Control Act of 1986 (IRCA), P.L ], in accordance with the applicability provisions and deadlines established in O.C.G.A EEV / Basic Pilot Program* User Identification Number BY: Authorized Officer of Agent Date (Subcontractor Name) Title of Authorized Officer or Agent of Subcontractor Printed Name of Authorized Officer or Agent SUBSCRIBED AND SWORN BEFORE ME ON THIS THE DAY OF, 20 Notary Public My Commission Expires: * As of the effective date of O.C.G.A , the applicable federal work authorization program is the EEV / Basic Pilot Program operated by the U.S. Citizenship and Immigration Services Bureau of the U.S. Department of Homeland Security, in conjunction with the Social Security Administration (SSA). 6