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Local Business Certification Form <br />(1) "Local business" shall mean a business that meets all of the followincriteria: <br />g <br />(a) Has had a staffed and fixed office or distribution point, with a verifiable street address, <br />located within Brevard; Indian River; Martin Okeechobee; Osceola; or St. Lucie County for at <br />least one (1) full calendar year immediately prior to the issuance of the request for competitive <br />bids or request for proposals by the County. Post office boxes shall not be used or considered <br />for the purpose of establishing a physical address; and <br />(b) Has had, for at least 12 months prior to the date of the advertisement for the particular <br />good or service being solicited, a current "Local. Business Tax Receipt" issued by Brevard; <br />Indian River; Martin; Okeechobee; Osceola; or St. Lucie County, if applicable; and <br />(c) Holds any license or competency card required by Indian River County; if applicable; and <br />(d) If the contract is awarded, will be the person or entity in direct privity of contract with <br />Indian River County and not as subcontractor, or any l <br />supplier. ower -tier subcontractor, materialrnan, or <br />1 _Company Name:= t vjbSF' �uyL-i 1i�a A I '- <br />r <br />2. Address.- - 1c Ptv I I --Vi 9� <br />177/ <br />3. If applicable, Contractor License or Competency; Card C) Aja <br />4. PLEASE ATTACH COPY OF CONTRACTOR LICENSE OR -COMPETENCY CARD <br />5. If applicable, Business Tax Receipt #: <br />6. PLEASE ATTACH COPY OF BUSINESS TAX RECEIPT <br />7 -Phone Number: T 7 a -56 4 - h( 00 <br />8.Fax Number 'Iq�- <br />9. 1 hereby certify that, If the contract is awarded, the entity set forth n eo <br />m 1 aw ill be the <br />person or entity in direct privity Of contract with Indian River County and not as subcontractor, or <br />any lower -tier subc ofr materialman, or supplier. <br />Signature: <br />Name and Title:'( sy l 1<6 -se <br />VENDOR PLEASE DONOT COMPLETE BELOW <br />To be completed by an authorized representative from Indian River County Purchasing Division: <br />Meets definition of Local Business _ YES NO <br />If NO, provide reason.- <br />Date.- <br />. <br />(Authorized Signature) <br />To receive Local Bid preference, this certification andcopies of all required documents must be <br />submitted with your Bid package. <br />00200-3 <br />